CIAX.COM, 5 LONGHEY RD, MANCHESTER, M22 8UA, UNITED KINGDOM
Tel: +44 161 902 0980 Fax: +44 161 945 8169 Email: help
CIAX.comFAX: +44 161 945 8169
| Please (1) Print this form. (2) Use a pen to fill the form. (3) Fax the form. Thank you. |
| CIAX.COM CIAX.COM, 5 LONGHEY RD, MANCHESTER, M22 8UA, UNITED KINGDOM Tel: +44 161 902 0980 Fax: +44 161 945 8169 Email: help CIAX.com |
FAX: +44 161 945 8169 |
| ORDER NUMBER: | DATE: |
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ADDRESS: Must be the billing address of the credit card |
| CONTACT: | COMPANY: |
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| CITY: | POST CODE / ZIP: |
| TEL: | FAX: |
| EMAIL: | <<< IMPORTANT: Email address for delivery of software |
| ORDER CODE | PRICE | QUANTITY | SUB-TOTAL |
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TOTAL: |
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| CREDIT CARD NUMBER: [ ] VISA [ ] MASTERCARD [ ] ACCESS [ ] SWITCH [ ] AMERICAN EXPRESS | |||||||||||||||||||||||||
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| SECURITY: Last 3 digits (or 4 digits) printed on back of your card, printed on the Authorised Signature strip usually. | |||||||||||||||||||||||||
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VALID FROM DATE: (Example: 04 / 2004) |
EXPIRY DATE: (Example: 06 / 2005) |
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SWITCH ISSUE NUMBER: (For SWITCH cards only) |
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CARD HOLDER'S NAME: |
CARD HOLDER'S SIGNATURE: |
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