----------------------------------------------------------------------- CREDIT CARD ORDER FORM (Rev 1.23) ----------------------------------------------------------------------- 1) REMEMBER TO ADD Credit Card banking charge to TOTAL COST for your order: V/B/M Cards:3%, Amex:5%. Prices are discounted based on C.B.D. 2) We do NOT accept credit cards for International orders. Instead pay by Telegraphic Bank Money Transfer or Western Union Money Transfer. 3) Please provide a real PHYSICAL delivery address. Not P.O. Box. 4) This order MUST be PRINTED and FAXED TO 03-96905331 or Scan Emailed or POSTED back to us WITH THE CARDHOLDER'S SIGNATURE clearly shown. ---------------------------------------------------------------------- ORDER DETAILS OF GOODS OR SERVICES AND ANY SPECIAL INSTRUCTIONS: ---------------------------------------------------------------------- DELIVERY DETAILS: NAME/ORGANISATION/BUSINESS_____________________________________________ CONTACT PERSON IF BUSINESS_____________________________________________ STREET AND NUMBER (NOT P.O. BOX!)______________________________________ SUBURB_________________________________STATE__________ POSTCODE________ CONTACT PHONE NUMBER (WORK)_________________ (HOME)____________________ CONTACT FAX NUMBER (IF AVAILABLE)(WORK/HOME)____________________ EMAIL ADDRESS (IF AVAILABLE):__________________________________________ CREDIT CARD DETAILS: CARD TYPE: ___VISA ___MASTERCARD ___AMEX CARD NUMBER:________ ________ ________ ________ Security Code:________ EXPIRY DATE: (MM/YY) ____/____ CARDHOLDER NAME:______________________________________________________ CARDHOLDER SIGNATURE__________________________ TODAY'S DATE: ____/____/________ DD / MM / YYYY TOTAL AUTHORISED CREDIT CARD DEBIT: $___________________ I hereby authorise Micronica to irrevocably debit my credit card for the total amount shown. I agree to the MICRONICA terms and conditions of trade as displayed at www.micronica.com.au/order. I understand that this order is irrevocable and non-refundable. I understand I am liable for all charges incurred in relation to this order and that I will be billed accordingly. ---------------------------------------------------------------------- For enquires contact: Micronica, 184 Napier Street,South Melbourne,3205,Victoria,AUSTRALIA Tel: 03-96998844, Fax: 03-96905331, Email: micronica@micronica.com.au Web: www.micronica.com.au ----------------------------------------------------------------------