Surgeon & Safari – Credit Card Payment Form

surgeo-and-safari

"Lorraine was extremely helpful during the whole process and is very open and warm as a person."

Mary

Fax back Credit Card authorisation form. Please fill out this form, then print, sign and fax it to Surgeon and Safari

(+27 11) 706 5582

I the undersigned hereby authorise Surgeon and Safari to deduct from my account funds as agreed upon and stipulated on the form below.

Name
Surname
Date of Birth
Postal Address
Country
Email Address
Telephone
Passport number
BILLING INFORMATION
Anount in ZAR	ZAR
Is billing address the same as above	YES NO
Specify details if different from above
Initials on Credit Card
Surname on Credit Card
Billing address for Credit Card
Credit Card
3 Digit authentication number on reverse
Credit Card Number
Expiry Date
Signature

Please be assured that all electronic data received is treated with the strictest confidentiality.

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