Monomax ltd p. O. box 168 St. Petersburg, 195112, Russia icon

Monomax ltd p. O. box 168 St. Petersburg, 195112, Russia



НазваниеMonomax ltd p. O. box 168 St. Petersburg, 195112, Russia
Дата конвертации14.09.2012
Размер8.15 Kb.
ТипДокументы


MONOMAX LTD. p.O. box 168

St. Petersburg, 195112, Russia


Tel.: + 7-812-320-01-19 Fax: +7-812-324-73-22,

E-mail: anna.danilova@monomax.org Web: http://www.monomax.org

FSSCEF-2004. Agreement of payment

Note: All fields required



I, ____________________________________________, agree to pay the following amount as a

security deposit or full payment for:

  1. ________________________________________________ AMOUNT________________

  2. ________________________________________________ AMOUNT________________


Address:_________________________________________________________________________


City:____________________________________________________________________________


State/Province:____________________________________________________________________


ZIP/Postal code:___________________________________________________________________


Phone numbers:___________________________________________________________________


Fax numbers:_____________________________________________________________________


E-mail address:___________________________________________________________________


TYPE OF CREDIT CARD:


______VISA _______MASTERCARD ______AMERICAN EXPRESS ______ DINERS


CREDIT CARD NUMBER:_________________________________________________________


EXPIRATION DATE:_____________________________________________________________


NAME ON CARD:________________________________________________________________


TOTAL AMOUNT : _______________________________________________________________

In case of credit card payment 3% for banking operation is retained.



I hereby authorize Monomax Ltd.
to debit the above credit card account for the total amount due



(Required) CARD HOLDER SIGNATURE:____________________________________________


DATE:________________________




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