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                      CREDIT CARD ORDER FORM (Rev 1.26)
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1) REMEMBER TO ADD Credit Card banking charge to TOTAL COST for your
order: V/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 form can be printed and Scan Emailed or Posted back to
us WITH THE CARDHOLDER'S SIGNATURE clearly shown.
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ORDER DETAILS OF GOODS OR SERVICES AND ANY SPECIAL INSTRUCTIONS:





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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 (Tick): 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.
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For enquires contact:
Micronica, 184 Napier Street,South Melbourne,3205,Victoria,AUSTRALIA
T: 03-96998844, E: micronica@micronica.com.au, W: www.micronica.com.au
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