Pete's Luminous Creations

International Plaza
10 Anson Road, #15-14
Singapore 079903

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AUTHORIZATION TO CHARGE CREDIT CARD

COMPANY NAME  
EMAIL ADDRESS:   
NAME ON CARD:        
TYPE OF CARD: (Visa / Master / American Express / Discover) *
CREDIT CARD NUMBER  
 EXPIRATION MONTH:      EXPIRATION YEAR:  
BILLING ADDRESS ON CREDIT CARD  
INVOICE NUMBER  
PRODUCTS ORDERED  

*I/We hereby authorize Pete's Luminous Creations to debit *my/our card for the amount of US$ _____________

I have also included a photocopy of the credit card used (both front and back), and have signed the photocopy.

Card Holder Name: ________________________________

 

Signature: ______________________________ Date: _______________

INSTRUCTIONS:
Please Print, Sign and Date this document and Fax it to Pete's Luminous Creations
at Singapore Fax: (65) 6726 0822
We would proceed with this order once we have received this authorization.