Pete's Luminous Creations
|NAME ON CARD:|
|TYPE OF CARD:||(Visa / Master / American Express / Discover) *|
|CREDIT CARD NUMBER|
|EXPIRATION MONTH:||EXPIRATION YEAR:|
|BILLING ADDRESS ON CREDIT CARD|
*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: _______________
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.