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CRED IT CARD TRANSACTION FORM

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CRED IT CARD TRANSACTION FORM Powered By Docstoc
					Australian Design Rules
Payment Transaction Form
1. Subscription Options - ADR CD (2nd and 3rd Edition) Australian Subscribers With Subscription Per Year Without Subscription/One-Off 2. Payment Options Electronic Funds Transfer (EFT) Bank: Reserve Bank of Australia, Canberra [swift: RSBKAU2S] Account Name: DITRDLG Official Departmental Main Account Credit Card Please charge: Credit card number: Cardholder’s Name: Signature: Bankcard MasterCard Visa For the amount of $ ______._____ Expiry date: BSB: Account Number: Reference: 092 009 110951 Quote ‘ADR’s’ $70.60 ($6.42 GST inc) $23.55 ($2.14 GST inc) Overseas Subscribers $AUD64.18 (tax-free) $AUD21.41 (tax-free) Qty Total $AUD $ $

Cheque Payable To: Receiver of Public Monies.

3. Your Mailing Details

Contact Name

Company Name

Postal Address

Phone ( ) (

Fax )

Email State: Country: Postcode:

4. Return the Completed Form by

Fax the completed form to: 02 6274 7979 or Overseas: +61 2 6274 7979

Email the completed form to: Standards@infrastructure.gov.au

Post the completed form with your payment option completed above to: ADR Subscriptions, Vehicle Safety Standards [A2E] Department of Infrastructure, Transport, Regional Development and Local Government GPO Box 594 CANBERRA ACT 2601, AUSTRALIA

Office Use Only Received Date: _____________ Customer No: _____________

ADRCDROM_Payment_oct08.doc Despatched Date: _____________

GPO Box 594 Canberra ACT 2601 Australia  Telephone: 02 6274 7684 Facsimile: 02 6274 7979 Website: www.infrastructure.gov.au  ABN 86 267 354 017


				
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