Fax
Payment Form
Please print and complete form, faxing to one of the following:
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Quote Number:________________________ First name:
_______________________ Last
name: _________________________ State: ___________________ Country: __________________ Zip: _________ Telephone: __________________ Fax: __________________ Email: _________________________
URL:
________________________________ Card Number: _______________________________________________ Name as appears on card: ______________________________________ Expiry Date: _________________ Amount in figures: ______________________ Amount in
words: _____________________________________________________ I hereby
authorize Global Design to charge the above amount to my credit card,
in exchange for services being supplied as per my quote, which are guaranteed
by Global Design.
Date: ____________________ Signature:
_______________________________________________ Additional comments: ___________________________________________________ _____________________________________________________________________
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