"VISA
EXPRESS"
NAME:
SURNAME:
(FIELDS MUST CONTAIN ALPHA (i.e A-Z)ONLY.
ADDRESS:
CITY:
(FIELDS MAY CONTAIN ALPHA AND NUMERIC).(MUST BE A VALID ADDRESS).
STATE:
COUNTRY:
POSTAL CODE:
(FIELDS MAY CONTAIN ALPHA AND NUMERIC)
ITEM DESCRIPTION:
(FIELDS MUST CONTAIN ALPHA (i.e A-Z)ONLY.
QUANTITY:
AMOUNT:
(FIELDS MUST CONTAIN NUMERIC(i.e 0-9)ONLY.
AMERICAN EXPRESS CARD#:
EXPIRY DATE:
(FIELDS MUST CONTAIN VALID CARD INFO).
I THE ABOVE MENTIONED NAME, HEREBY CERTIFY
THAT I HAVE FILLED OUT THIS FORM AS INSTRUCTED,
THE ABOVE INFORMATION IS TRUE AND CORRECT AND
AGREE THAT ALL SALES ARE FINAL AND WITHOUT LIABILITY.
