Kima Global Publishers
CREDIT CARD PAYMENT FORM
Visa or Master card only
For security reasons phone us on 021 7824463 if you are about to fax us your details - If you want to email your card information, you have send the card holder name - phone number and the card number in three separate emails for security reasons

Please read through the Form and confirm that all the details are correct before Printing the Form.

FAX the Form to FAX # +27 021 7824982

Cardholder's Name:
Full address .........................................

 

 Cardholder's
Phone Number:
........................................

 

 Card Number:
........................................

 
Card Type: VISA / MC Expiry Date:

........................................

 last 3 digits at the back of card

........................................
titles:
 
 
Total Amount paid: R

................................................................................

I confirm that the above information is correct. I authorize Kima Global Publishers to debit my Credit Card for the Amount
and Invoices as specified on this form.

 
Card Holder's Signature: