PLEASE PRINT THIS PAGE IF YOU WISH TO PAY FOR YOUR SHOES BY CREDIT CARD. COMPLETION OF THIS FORM AUTHORIZES AW BARLOW SHOE STORES P/L TO CHARGE THE PRESCRIBED AMOUNT AGAINST THE CARDHOLDERS ACCOUNT.
ABN - 84 007 873 396
PH. - (08) 8223 5157
CARDHOLDER NAME ............................................................................
PHONE............................................................................
TYPE OF CARD...............................................................................
CARD NUMBER........................................................................
EXPIRY DATE...............................................................................
ADDRESS FOR DELIVERY OF GOODS (NOT A PO BOX)
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STOCK ORDERED.....................................................................
PRICE..............................................................................
POSTAGE........................................................................
TOTAL.............................................................................
CARDHOLDERS SIGNATURE - ..........................
DATE ..............................................................................
PLEASE RETURN BY FAX TO (08) 8223 2358
