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| MAIL ORDER REQUEST FORM |
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I ___________________________ HereBy Authorize SERVICES INTERNATIONAL
(Cardmember Name)
to charge my card for the services rendered
Card Number ___________________________________________________________
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Card Expiry Date ___________________________________________________________
Billing Address ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Home Telephone Number |
___________________________________________________ |
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Work Telephone Number __________________________________________________ |
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Mobile Telephone Number __________________________________________________ |
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| Present Address______________________________________________________________ |
___________________________________________________________________________ |
___________________________________________________________________________ |
___________________________________________________________________________ |
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Amount of Charge(In Local Currency) _________________________________________
Amount of Charge(In Indian Currency) _________________________________________
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I understand that the Record of Charges - In respect of services received /availed-submitted by you to the Credit Card Signature nor the imprint of the card and i therefore undertake unconditionally honour and pay without any demur a mentioned above as when i am billed for the same. |
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Thanking you,
Yours sincerely,
(Signature as it appears on the Card)
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| Name : |
| Date : |
| To be filled by Merchant Establishment |
Merchent Number __________________________________________________________ |
Merchent Name __________________________________________________________ |
Fax Number __________________________________________________________ |
Contact Number __________________________________________________________ |
Contact Person __________________________________________________________ |