AUTHORIZATION

 

Hereby I authorize ________Oksana Gumenyuk & Oksanas LTD______________________to

Charge my credit card for the service of your company without my additional instructions

 

Please print

Cardholder’s Name:

 

 

 

Company

(if corporate):

 

 

Issuing Bank:

 

 

 

 

 

 

Card Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expire Date:

 

 

Card type Visa/Mastercard:

CVV2/CVC2

(3 digit number on back of card)

American Express:

Batch Code (4 digit number on the right above the account number)

 

 

Cardhold Passport #

 

 

 

 

Cardholder’s address, Phone, Fax, E-Mail:

 

 

Amount of rubles in words:

 

 

Amount of rubles in figures:

 

 

 

Cardholder’s signature:_______________________________________Date:_________________

 

Please Fax to Oksana's at: +1(202)449-8334 or +7(812)312-1271 Fax
  or scan and e-mail to  info@nevsky88.com