ABN 83878708551 

Credit Card Payment Request

Write clearly please 

CONTACT PERSON:                                                    

ADDRESS:                                                                                           

                                                                                                   POSTCODE:                     

PHONE:                                                     

EMAIL:                                                     

Please accept payment for OZTL_NET advertising.
Price is $110 (or $115.50 if a receipt is required) [GST inclusive].

Debit my Visa, MasterCard, American Express (circle one) 

for the amount of  $              

Card Number:                                                                                       Expiry Date:       /    

Cardholder's Name: (please print)                                                      

Cardholder's Signature:                                                     

PRINT AND SEND BY FACSIMILE:   ATTN.  JEN BRAITHWAITE    +61 2 69332733