DER HERR

AUTHORIZATION FORM

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Full Name : Province :
Street :       Postal Code :
City Passport/ID
Country : Tel :
Area Code : Email :
Fax :

Dear Mr. Steve, (DER HERR)

I, HERE BY AUTHORIZE DER HERR TO PROCEED WITH MY ORDER AS MENTIONED ABOVE AND TO DEBIT THE SUM OF FROM MY CREDIT CARD SPECIFIED BELOW.

AMERICAN EXPRESS
MASTER CARD
VISA CARD

CREDIT CARD NUMBER:

EXPIRY DATE : (DD/MM/YY)

FOR AMERICAN EXPRESS PLEASE MENTION THE FOUR DIGIT NUMBER APPEARING ON THE ENTER RIGHT HAND CORNER OF YOUR CARD TO PROCESS

(PLEASE FAX / MAIL OR EMAIL THIS LETTER TO DER HERR)

TEL : +(66 2) 2552212 / 2543529 / 2534945, FAX : +(66 2) 2543515

E-MAIL : steve@derherr.com

Please note :- Der Herr reserve the rights to treat all information provided as strictly confidential and intended for one single use only.