|
a)
Your Order (please fill in
details below) |
| Qty |
Description |
Price (AU$) |
_____ |
_______________________________________________________________________ |
__________ |
_____ |
_______________________________________________________________________ |
__________ |
_____ |
_______________________________________________________________________ |
__________ |
_____ |
_______________________________________________________________________ |
__________ |
| |
Total excluding
freight (AU$): |
__________ |
|
1) Postage and
packing (freight) is automatically added to your order if you
use the shopping cart at extonaustralia.com.
2) If you choose not to use the shopping cart and fax/post your
order then we will confirm the freight charge with you before
dispatching your order.
3) International orders will be sent by First Class Airmail.
4) Any Customs Duty or Taxes levied by the country to which the
product is sent is the responsibility of the purchaser.
|
|
| b) Payment Details
(information below marked with ** is mandatory) |
| **Card type |
|__|-Bankcard |__|-Mastercard
|__|-Visa |__|-American Express |
| **Card holder's name |
________________________________ |
| **Card number |
__ __ __ __ - __ __ __ __ - __ __ __ __ -
__ __ __ __ |
| **Card expiry date |
___________ |
| **CVV Code |
_________ (Numbers following the card
number on the signature strip on back of card) |
| **Signature
|
____________________________
|
c) Your Name
(if different from cardholder's name) |
________________________________ |
| **Street |
________________________________
|
| **City |
____________________________ |
| **State |
____________________________ |
| **Post Code |
___________ |
| **Country |
____________________________ |
| **Email Address |
____________________________ |
| Phone Number |
____________________ |
| Fax Number
|
____________________
|
d) Name for delivery
(if different from above) |
________________________________ |
| Street |
____________________ |
| City |
____________________ |
| State |
____________________ |
| Post Code |
____________ |
| Country
|
________________________________
|
| e) Special instructions
|
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________ |