1. BILLING DETAILS
First Name:____________________________________________
Last Name:____________________________________________
SHIPPING ADDRESS
Street:____________________________________________
Town/City:_________________________________________
Province/State:_____________________________________
Country:__________________________________________
Post/ Zip code:_____________________________________
CONTACT DETAILS
Home Phone No.______________________________________
Work Phone No:_______________________________________
Fax/Mobile No: ________________________________________
E-mail address:________________________________________
[ ] MasterCard*
[ ] VISA*
[ ] American Express*
[ ] Diners Club*
[ ] Personal Cheque (Australia only)
[ ] Money Order (In Australian Dollar only)
* If you have selected to pay by Credit Card, please
supply your Credit Card details below:
Card Holder:_________________________________________
Card Number: |___|___|___|___| |___|___|___|___| |___|___|___|___| |___|___|___|___|
Expiry Date: |___|___| / |___|___| (mm/yy)
I hereby confirm that all the information supplied is true and correct.
____________________________________________________
Signature (Please sign your name)
Mail this form to:
Bearz by Ilzé
PO BOX 6130
Conder, ACT 2906
Australia
Would you like to have your parcel insured? [ YES ] [ NO ]
