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 |