American Express
American Express
(There will be an additional charge of 3 %. Please fill the following form and fax to us or send as an attachment the format and credit card copy from both the side)
PLEASE FILL THE FOLLOWING FORMAT & FAX/MAIL TO US
I ___________________________ (Cardmember Name) Hereby authorize
Services International Ltd. to charge my American Express Card an amount of
Rs.__________________ for the Servies rendered.
Card number:
Card expiry date: __ __ / __ __ __ __ [MM/YYYY]
Billing address ___________________________________________________________________
_________________________________________________________________________________
City ___________________________________ Pin Code: _______________
Telephone: ( )____________________________ Mobile: ________________________
I understand that the Record of charges in respect of Services Recieved / Availed by me, submitted by Merchant Establishment as mentioned below to American Express Banking Corp. will neither bear my signature nor the imprint of the Card and I therefore undertake to unconditionally honor and pay without any demur and contentions, the charges as and when I am billed for the same by American Express Banking Corp.
Thanking you,
Yours sincerely,
(Signature as it appears on the American Express Card)
Name: ________________________________________________________________
To be filled by Merchant Establishment
Merchant number __________________________________________
Merchant name ____________________________________________
Fax Number _______________________________________________
Contact Number ____________________________________________
Contact Person _____________________________________________
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