Internet/Mail ORDER
1] SECTION TO BE FILLED BY THE CARD HOLDER
Family Name: _______________________ First Name: ____________________
Family Status: ٱSingle ٱMarried ٱDivorced Date of Birth: / /
Company Name: _____________________________________________________
Type of Business: _____________________________________________________
Full Address: ________________________________________________________
City: _______________________________Country: ________________________
P.O.Box: ___________________ Tel: ________________ Fax: ________________
1) _____________________________________ Amount (US$): ____________
2) _____________________________________ Amount (US$): ____________
If Hotel reservation, please mention duration of stay: from __________ till ________
MasterCard Visa Card Number ∟∟∟∟ ∟∟∟∟ ∟∟∟∟ ∟∟∟∟
Expiry Date: --- / --- CVC2/CVV: ∟∟∟ (Please write the 3 digits printed on the signature panel on the back of the card) Issuer Bank _______________________________ Country: ____________
I accept the following terms and conditions:
I understand and admit that deposit is not refundable in all cases
I hereby certify that all the information given in this order request is true and correct to the best of my knowledge. By submitting this form along with a copy of my card and my passport, I fully authorize Merchant Name ____________________________ to bill my invoice to the above mentioned card without my prior consent for a total amount of US$ __________________. This request is accepted by me and can not be revoked.
Name: _______________________Date: _______________ SIGNATURE: _______________
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2] SECTION TO BE FILLED BY THE MERCHANT
Att: Bank Audi Sal - Audi Saradar Group
Electronic Banking & Card Services
Merchant Section – Fax: 01-219960
Kindly execute this transaction under my full responsibility.
Merchant Name:_____________________ Authorized Signatory: __________________
Stamp & signature: ___________________ Date: __ __ / __ __ / __ __