Payment Details - Fax or Mail Order
This form may be used in the following way with Fax or Mail orders -
  • Print blank copy, complete relevant boxes manually, then fax or post
  • Complete relevant boxes, print completed form, sign, then fax or post
  • Remember - fax or mail copies must be signed by Cardholder

Ref: Order Number

(only if you know your order number)
Please enter details below

Card Type

Please enter the last 3 digits of the number on the signature strip below

Name of issuing Bank

Card Number

Card Issue Number*

*Start Date/Issue Number - Switch and Solo Cards only

Cardholder's Name (as it appears on card)

Card 'Expiry' date

 
Card 'Valid From' date

 

Address at which the card is registered

(Cardholder's full postal/billing address)

Landline telephone to the registered card address (Required)

Delivery address

(if different)

Conditions apply

Mobile telephone or any number that might be useful for contact during the daytime (Helpful)
Cardholder's Signature
 
Date
 

www.showerright.co.uk

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