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