Etumax Corporation Credit Card Payment Form
I hereby request and authorise Etumax Corporation Shn Bhd to charge my credit card for the order below.
  Product Name Quantity Price
1      
2      
3      
4      
5      
6      
7      
8      
9      
10      
      Shipping and handling + USD 10
    Total Amount : USD
  Details Of Credit Card
Cardholder's Name (as appear on credit card)
Type of Credit Card (Please tick either one)      Visa      MasterCard
Credit Card No. Card Security Codes
- - - ** last 3 numbers printed on the signature strip
Expiry Date (MM/YY) All information entered on this form will be kept strictly confidential by
- Etumax Corporation Sdn Bhd. Please FAX TO +603 79609908.
  Shipping Address
Full Name :
Address :
Street 1 :
Street 2 :
City :
Post Code/Zip Code :
Country :
 
Email :
Contact No :
(HOME)
(MOBILE)
(FAX)
Cardholder's Signature
(as appear on credit card)
Date :
  For Office Use
Date Received :    
Date Processed :
Verified By :