CREDIT CARD - Please print out this page, fill in your credit card detail, order, sign and fax it to us.
ELECTRONIC PAYMENT - if paying by EFT (Electronic Fund Transfer) complete the order form and fax it to us and tick the EFT payment block below and please use your Cell Phone number as Reference when transferring money and mail the proof of payment to orders@ageless.co.za or fax the proof of payment to us. Our bank details...
Please debit my credit card |
I will be transferring funds via EFT |
Name as on card |
Type of card (please circle applicable one) |
Visa | MasterCard | American Express | Diners Club |
Expiry date |
Month | Year |
Card number |
- |
- |
- |
CCV number of credit card (see information...) |
Signature (as on card) |
|
e-mail address |
Contact telephone number (preferably cellular number...) |
Delivery address - South Africa (see information...) |
Postal code (we need it for courier delivery as well) |
Item |
Price |
Total |
R |
R |
|
R |
R |
|
R |
R |
|
R |
R |
|
R |
R |
|
Delivery (Courier) We will provide you with a quote |
R | |
Total due |
R |