CREDIT CARD CHARGE AUTHORIZATION

FOR PURCHASE BY MAIL

PRODUCTS  OF "THE IRISH STORE" - www.irlanda.it

(TO SEND, FULLY FILLED, To the FAX N. 00392 5830 6066)

 

 

1) FIRST NAME___________________LAST NAME__________________

 

3) BIRTH DATE ______/_______/_____

 

4)CREDIT CARD NUMBER (choose one):

 

VISA/MASTERCARD |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|

 

 DINERS |__|__|__|__| |__|__|__|__|__|__| |__|__|__|__|

 

 EXPIRATION DATE (EXP GIVEN) |__|__| |__|__|

 

AUTHORIZED AMOUNT (*):

 

EURO, |__|__|,|__|__|

 

IN LETTERS:

 

euro___________________________________/_____cents

 

 

SIGNATURE FOR AUTHORIZATION ____________________

 

(*)"I received mail of confirmation of the availability of the goods 

and of the amount that I am authorizing ".

"Moreover I would like to know the arrival date, my address is

 

___________________ญญญญญ__________(|__| by  e.mail|__|by sms**)

(**please fill complete phone number)

(TO SEND FILLED To the FAX N. 00392 5830 6066)

      
Credits | Licenza