REVOM
bvba, Prof. Devochtstraat 72, B 2300 Turnhout
Tel +32 (0)14 420571 - Mobile Tel (GSM) +32 (0)475 629852 - Fax +32 (0)14
420571
Authorization to charge a CreditCard
We kindly ask you to print this document, and to sign it, with the handwritten mention:
'Read and approved'.We invite you to fax a copy of it to REVOM bvba at 0032 14 420571
The original must be sent by postal mail to:
REVOM bvba - Prof. Devochtstraat 72 - B 2300 TurnhoutWe shall process your order upon receipt of the fax.
Do not send this document by e-mail
Les informations contenues dans ce document seront traitées de manière confidentielle, dans le seul but d'effectuer le prélèvement sur carte de crédit. Aucune de ces informations ne fait l'objet d'un enregistrement permanent dans un fichier quelconque, informatique ou autre.
| I undersigned | ||
| Last Name | ||
| First Name | ||
| Street, nr | ||
| Zipcode | ||
| City/State | ||
| Country | ||
| Tel | ||
| Fax | ||
| VAT | ||
| Owner of the CreditCard | ||
| Type | ||
| CardNumber | ||
| Expiration date (month/year) | ||
|
Creditcard Validation
Value code CVV - CVC - CID |
Visa &
MasterCard: 3 digitcode from the back of the card American Express: 4 digitcode from the front of the card |
|
| Identity which is embossed on the card | ||
| authorize REVOM bvba, Prof. Devochtstraat 72, B 2300 Turnhout | ||
| to charge the above mentionned card by the amount of EUR | ||
Date |
||
| Signature of the card owner, with the handwritten mention 'Read and approved' | ||