Letter of Authorization

I would like to proceed with my order of suits / catalogues from Pierre Boutique
FULL NAME :
PASSPORT NO :
STREET :
CITY :
COUNTRY :
PROVINCE/STATE :
POSTAL CODE :
AREA CODE :
TEL :
FAX :
E-MAIL :

I hereby authorize Pierre Boutique to
Deduct the sum of US$
From my Cradit Card :
Card Number :
Name on Card :
*Digit Code :
Expire Date : (MM/YYYY)
*Please See location of credit card digit code or VISA(3digit) from the right-hand picture
VISA 3 digit

............................................................
Signature as on cradit card
............................................................
Order once placed cannot be cancelled

Please deliver my goods / catalogues to ( Leave blank if address same above )
FULL NAME :
STREET :
CITY :
COUNTRY :
PROVINCE/STATE :
POSTAL CODE :
AREA CODE :
TEL :
FAX :


** PLEASE PRINT THIS FORM & FAX THIS TO **
Pierre Boutique FAX: (662) 6560663