Your total order value :  $

Discounts $

Balance Payables :

 

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Name on Card

Billing Address

Expiry Date

Credit Card No.

Remark :

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Please print our the following form and fax us on the 91-22-8215249 or 91-22-6234528.

To: Nisha's Glaomur Soft

xxxxxxxxx

xxxxxxxxxx

xxxxxxxxxxxx

Subject : Order No...............................

 

I Mr. ................ here by authrize to Nisha's glamour soft to chrage my card US $ .......... My Credit card detail are as under:

name

card no.

exprey

Below this message please paste the xerox copy of your Credit Card from front and back side both:

 

Authriozed Signatuary of the Card Holder:

 

 

__________________

( Mr......................  )