JAVA HANDICRAFT CENTER

(INDONESIA)

APPLICATION FOR CREDIT CARD PAYMENT

 

I would like to order the below referenced goods from you and wish them to be charged to my Credit Card.

ITEM

QUANTITY

DESCRIPTION

PRICE US$

 :

 

 

 :
       
       
       
       
       
   

Courier/Post and Packaging.

 
   

Sub Total

 
   

Credit Card charge 3% of total

 
   

Grand Total Due US$

 

Please debit my preferred Credit Card as indicated :

 VISA CARD  MASTERCARD (Please Tick)   Expiry Date: __ / __ ( mm / yr)
FULL NAME AS PER CARD : ________________________________ (Please Print in Block Capitals)
ACCOUNT NUMBER :    
(PLEASE FILL IN YOUR CREDIT CARD A/C NUMBERS LEGIBLY IN THE ABOVE BOXES)






CARDHOLDER ACCEPTANCE SIGNATURE : ___________________________

Please Fax back this duly completed form to Fax number +62 (21) 314 1111 , Java Handicraft Center, Indonesia.



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