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Pay by Fax

Pay by Fax



Pure Health Cafe

Payment by Fax Form



Complete the CREDIT CARD INFORMATION FORM
and fax it to +61 2 6624 6589


We accept Visa or Mastercard

The credit card transaction will be processed through our PAYMATE merchant facility.

You will receive an email from our merchant when the credit card transaction is processed.

I authorise the following transaction to be charged to my credit card:

E-mail Address: *
Name
Address
City
Post Code
Country
Name on Credit Card
Credit Card Type - Visa or Mastercard
Credit Card Number
Expiry Date
Three Number Verification Number on Back of Card
Amount $
Order Number
Comments
Phone Number



Thank you

Please fax-return to our office.
Our fax number is + 61 2 6624 6589



Signature: _____________________________

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