DATE : ____________________
GALLERY 278 PRIVATE LIMITED
278 RIVER VALLEY ROAD • SINGAPORE 238319
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DATE : ____________________ GALLERY 278 PRIVATE LIMITED 278 RIVER VALLEY ROAD • SINGAPORE 238319
|
Download this form via Acrobat PDF
|
RE
: VISA OR MASTERCARD CREDIT CARD AUTHORISATION
AMEX CARD
| FULL NAME |
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| POSTAL ADDRESS |
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| EMAIL ADDRESS |
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| TELEPHONE NUMBER |
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| FAX NUMBER |
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| I ______________________________ (Full Name) on this __________ day of _______________ 20____, do hereby irrevocably authorise Gallery 278 Private Limited to debit my VISA / MASTERCARD credit card with the amount of S$____________________ being payment made for _____________________________. |
| NAME (AS PRINTED ON CARD) |
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| CARD NUMBER |
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| EXPIRY DATE |
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Sincerely yours,
__________________________________________ (signature as on card) Please write in block letters and fax to us at (65) 6737 0322. |