| 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:__________________________________________________(郵編:_______________
) |
| 聯絡人:____________
(email) _______________________________________________ |
|
電 話:(O)_________________________________(H)__________________________________ |
|
(FAX)______________________________________行動電話_____________________________ |
|
■收據資料
|
| 收據抬頭: _____________________________________統一編號:___________ |