Payment details by fax for:- Web Page Design Web Site Hosting Domain Name Services

Web Wyzard Facsimile Payment

Please print this page, complete the form using BLOCK CAPITALS and fax to: (0044) 0870 167 5694

Your Name:

Business Name:

Reference No:

Address:

Town:

County:

Post code:

Telephone:

Fax:

Card Type:

Please delete where not applicable:
Mastercard | Visa | Switch | Solo

Card Number:

Issue No

Expiry Date:

Name on Card:

Amount to be deducted:

Details of Order:

......... ..........