Please
typewrite before faxing back this form to +1 530 348-7482 |
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| Your name: |
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| Contact e-mail address: |
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| VISA billing address: |
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| Country: |
Today Date: d m y |
| Tel: number: |
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| How much you want to
deposit?: |
US
dollars:
maximum $ 5'000.- by VISA / $ 100'000.- by transfer |
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Paying For
Your Deposit by VISA |
| Name on Card: |
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| Card Number: |
- - - Exp. - (mm-yy) |
Any other comments:
eg any special requirements you may have |
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