| Empowerment for the collection of receivables by credit card | ||
| Recipient: | ||
| Company: | Sunshine-Seeds | |
| Owner: | Renate Krebs | |
| Street: | Harkortstr. 16 | |
| Zip code + City: | D-59229 Ahlen | |
| Phone: | +49 (0) 2382 80 50 75 | |
| Fax: | +49 (0) 2382 80 50 92 | |
| Hereby I/we authorise Sunshine-Seeds to debit my / us credit card with following data by Visa/MasterCard. | ||
| Order No.* | ||
| Name, first name:* | ||
| Credit card type:* | ||
| Card holder:* | ||
| Credit card number:* | ||
| Valid until:* | ||
| CVC2 or CVV2 or CVC* | (the last 3 digits on back of the card) | |
| Place, Date | Signature | |
|
via FAX to: +49 (0) 2382 - 80 50 92 Fields to fill out and then for the signature [print out ] this page |
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