Landbase Australia

LANDBASE AUSTRALIA CREDIT CARD PERMISSION FORM

LOCKED BAG 25 Gosford NSW 2250 Australia
Phone: (Australia) 0408 68 64 61 Phone: (International) +61 408 68 64 61
Fax: (Australia) 02 43 23 73 26 Fax: (International) +61 2 43 23 73 26
E-mail: lbase@ozemail.com.au URL: http://www.ozemail.com.au/~lbase/

DATE:

I .................................................................... HEREBY AUTHORIZE JAN BAETZ OF LANDBASE AUSTRALIA TO USE MY CREDIT CARD DETAILS FOR THE PURPOSE OF TOPPING-UP MY POSTAGE DEPOSIT ONLY UP TO THE VALUE OF AUSTRALIAN $60-00 IF POSTING MAIL NATIONALLY OR AUSTRALIAN $100-00 IF POSTING MAIL INTERNATIONALLY IF/WHEN REQUIRED.

CARD TYPE: VISA / MASTERCARD / BANKCARD (Please circle applicable)

CARD NUMBER: .....................................................................................................................................................

NAME ON CARD:....................................................................................................................................................

EXPIRY DATE:..........................................................................................................................................................

SIGNED:.....................................................................................................................................................................

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