■信用卡資料 |
信用卡別: |
□VISA CARD |
□MASTER CARD |
|
|
信用卡號______________________________________________ |
有效期限_____
年_____月 訂購日期_____年_____月_____日 |
訂購總金額_______________________________ |
持卡人簽名________________________(與信用卡簽名同一字樣) |
|
■訂戶資料 |
姓名:______________________________________________________________________
□男 □女 |
收件地址:□□□_________________________________________________________________ |
聯絡人:____________ (email)
_______________________________________________ |
電 話:(O)_________________________________(H)__________________________________ |
(FAX)______________________________________行動電話_____________________________ |
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收據抬頭:
__________________________________
統一編號:____________ |