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Credit Card Authority Form - Motorised Bicycles Australia

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Credit Card Authority Form - Motorised Bicycles Australia Powered By Docstoc
					                                      MOTORISED BICYCLES
                                       AUSTRALIA PTY LTD
                                                       13 Babbage Road, Roseville Chase 2070
                                  ABN 20 094 081 366      PH (02) 9882-BIKE (9228-2453)
                                                                Fax (02) 9982-6966

                        CREDIT CARD AUTHORITY FORM

Customer Name:__________________________________________________________________

Customer Address: ________________________________________________________________

State: __________     Postcode: __________        Phone Number (      ) _____________________

Cardholder name:_________________________________________________________________


Card
Number:

CARD TYPE                   TICK           Expiry Date: _______/_________
BANKCARD
VISA                                        Security Number
MASTERCARD                                  (American Express Only)
AMERICAN EXPRESS

Goods Purchased:

1. _______________________________________________________________________________

2. _______________________________________________________________________________

3. _______________________________________________________________________________


Amount Paying $___________________

Driver’s License# _____________________________ Expiry Date ______________________



Authorised Signature ___________________________________________________________


Authorised Signature Name (Please print) __________________________________________

              Note: Photocopy of both sides of Drivers Licence
                    Must be produced on separate form.
                         Please Fax Back to (02) 9982-6966
           Email: info@moped.com.au                         Web site: www.moped.com.au
NB: PLEASE Provide Clear Faxed Copy of
 Both Sides of Drivers Licence with Any
 Credit Card Order, No order will be
     processed unless this is done.



  Credit Card Authority Form must be
          Complete and Signed.
Fax to (02) 9982-6966 or Attach Scanned
       Copy To Email and send to
          info@moped.com.au




   Email: info@moped.com.au   Web site: www.moped.com.au

				
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