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CREDIT CARD AUTHORIZATION FORM PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN IT TO OUR OFFICE BY FAX: (08) 8232 4221 or BY REGULAR MAIL.

Name: ___________________________________________________ Cardholder Name: ________________Signature: ________________ Address:

______________________________________________ ______________________________________________

Credit Card Type: _____ VISA

_____ MASTERCARD

____ AMEX

Credit Card Number: ________ - ________ - ________ - ________ Expiration Date: ________ / ________ Card Identification Number : (last 3 or 4 digits located on the back of the credit card): ________

Amount Charged: $ ________________ (Aust) Invioce No: ________ FAX or send the authorization to:

Veeederline Pty. Ltd. L2 / 450 Pulteney St. Adelaide, South Australia , 5000. P. O . Box 6100, Halifax St, Adelaide, 5000 Phone (08) 8232 4220 Fax (08) 8232 4221


http://veederlinecomau-temp.fjstaging01.pbstaging.com/site/DefaultSite/filesystem/documents/veederli