Name on Card: | |
Email Address:(please provide your email address) | |
Address Line 1: | |
Address Line 2: | |
Country: | |
Passport Number: | |
Date of Birth: | |
Order Number: | (Given to you when confirming your order by fax or email.) |
I, hereby authorize Humnawaj's Boutique & Tailor to debit the sum of
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US$ | from my credit card below |
Credit Card | AMERICAN EXPRESS MASTER CARD VISA |
Card Number: | |
Valid Until: | Month: Year: |
For American Express, please mention the four digit number appearing on the center right hand corner. | |
For Visa Card, please mention the three digit number appearing on the back side of the card. | |
Signature as on Card | ____________________________________________ |
|
PLEASE FAX OR MAIL THIS FORM TO:
Humnawaj's Boutique & Tailor
G-13/12 Malviya Nagar, New Delhi 110017 India
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