WildMountain Store Fax Credit-Card Order

FANCHE Co.,Ltd. No 703, Sec 5, Chung Shan N Rd., Shih Lin District, Taipei. Taiwan.

TEL:02-28318055  FAX:02-28317886

CONTACT INFORMATION
Name：			Date： y m d
ID No：□□□□□□□□□□ Birth day： y m d
Card No：□□□□-□□□□-□□□□-□□□□				Authorized Signature
Card Type：□VISA □MASTER □JCB
Good Thur：□□/□□─□□/□□ APP Co：□□□﹙The Verso Last 3 No﹚
Phone：(Day) (Eve) (GSM)
Address：□□□
E-mail：
Invoice No：□□□□□□□□ Tital：
Merchant No	01-016-6125-2	APP. Code

SHIPPING INFORMATION
Name：		Phone：
Address：
ORDER INFORMATION
	Product Name		Price	Qty	Total
1
2
3
4
5
6	Tax 5%
7	Shipping Cost
Total
I AGREE TO PAY TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT(MERCHANT AGREEMENT IF CREDIT VOUCHER)