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Credit Card Order Form - Supplies Only

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which is supplied to us will be held in the strictest confidence.

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I wish to order the following items

No. Item Price Total Cost

Subtotal

P & P

TOTAL COST

PAYMENT DETAILS

IMPORTANT : THE FOLLOWING INFORMATION IS ESSENTIAL.

Type of credit/debit card :

visa card mastercard american express

delta maestro solo jcb

Name of Issuing Bank / Building Society / ect.,

Card Number:
--- --- --- --- (Maestro/Solo Only)

Security Code

Start Date (if present) --- Expiry Date : ---

Maestro/Solo Issue Number (if present)

Cardholder's Name - Exactly As Printed On Card

Cardholder's Name/Address (if different)

Name
Number/Street
Village/Town
County/State
Other County/State Not Listed (please specify)
          Zip/postal code
Country
Other Country Not Listed (please specify)

Total Amount of Sale :   Pounds Sterling

Your Title : Other Not Listed (please specify)

First Name/s   :
     Surname   :
POSTAL ADDRESS
Number/Street :
Village/Town    :
County/State
Other County/State Not Listed (please specify)
Zip/postal code   :
Country
Other Country Not Listed (please specify)
* Required  Telephone   :
         Facsimile   :

* Required  Email Address :

* Required  Confirm Your Email Address :

Delivery Address (if different)
Number/Street :
  Village/Town   :
County/State
Other County/State Not Listed (please specify)
Zip/postal code   :
Country
Other Country Not Listed (please specify)

Click once only on Submit to send or Reset to clear form.

We will acknowledge, by E-Mail, receipt of this Credit Card Order Form usually within 48 hours.
If no contact is made in this time please contact us by direct E-mail or any other method.

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