Type of Credit Card to Use (MC/VISA) :
Credit Card Number                   :
Credit Card Expiration Date          :
Your Full Name                       :
Card Holder's Name (From Card Face)  :
Card Holder's Address                :
Card Holder's City or Town           :
Card Holder's State or Country       :
Card Holder's Zip or Postal Code     :
Card Holder's HOME Telephone Number  :
Card Holder's WORK Telephone Number  :