Mastercard or Visa Credit Card Mail Order Form

Please print this form on your local printer & fax the filled in form to 91-22-23879388 along with the Xerox copies of both sides of your Credit card & a valid proof of ID (Driving license, Passport, Pan card, Election Card etc). Your receipt will be mailed to you on receipt of this payment.

(For foreign national credit card holders please fax your passport & visa copy)

Name (As Punched on the card):

Postal Address:

Email address:

Tel Nos:  (R)                                                      (O)

Credit Card Number:

Card Type: Mastercard / Visa

Expiry Date:

Amount: (In Figures)

Amount (In Words)

Today's Date: (dd/mm/yy):