Date :
Merchant address : HANUSOVA 288/8, 140 00 PRAGUE 4, CZECH REPUBLIC
Name of author. merchant : Gabriela Justinova

Price :

Cardholder will fill the following information :

Name and surname of the cardholder :

Address :

Tel., fax :

Card number :   . . . .    . . . .    . . . .    . . . .

Card validity :

Last three digits printed on the signature panel:

EUROCARD-MASTERCARD/ CVC2 – Card Validation code 2:    . . .

VISA/CVV2 – Card Verification value 2:    . . .

According to my request I wish to pay the ordered introduction services by my credit card. All stated information above is correct and true.

Order date :

Signature of authorised cardholder :

………………………………………………………………

Please complete the form, sign it, and fax it to our Office at: ++420-224874201. From U.S. dial 011-420-224874201

The price for the service will be charged in the Czech currency (CZK) in the amount that corresponds with the daily exchange rate.
Price does not include VAT.