	Beth Anne Gray J., LL.B. (Hons.) & Victoria Tejada LL.B. P.O. Box 832-0816 - World Trade Centre - Panama City - Republic of Panama International Legal Services

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Credit Card Authorisation Form

We accept Visa & Mastercard only.

Please print this page. Fill the form in - please print clearly, and sign where indicated.

You must include with this Authorisation form a copy of the front and back of the credit card, as well as a copy of your passport or ID card.

Charge Total	US$
Description
Card Type:	Visa	Mastercard
Card Holder Names
Credit Card No.		Validation No.
Expiration Date			(dd-MONTH-yy)
Billing Address*
Telephone No.		Passport No.

* This should match your credit card statement address.

Please sign and fax this form to us on +1 (305) 675-2354.

Please remember to include with this Authorisation form a copy of the front and back of the credit card, as well as a copy of your passport or ID card.

____________________________

Your signature should match the signature on your passport/credit card.

For questions or comments, please write to the webmaster

Last modified 26-Sep-2007 17:37 -0400