1 - Ashirwad Enclave,
Ballupur,
Dehradun 248006,
Uttaranchal,
INDIA
Fax +91 135 2764600
email:
cosmeticsurgeonindia@gmail.com
AUTHORIZATION FOR COLLECTION OF
FEE THROUGH CREDIT CARD
Kindly charge my credit card (details
given below) a sum of Rs 4500/= (Rupees Four Thousand
five Hundred only) as advance for incidental charges and the
transportation from New Delhi Airport to Ashirwad Hospital,
Dehradun.
Name as on
Card ………………………..
Credit card type
VISA / MASTERCARD
Credit card number
---- ---- ---- ----
Date of expiry of
card mm/yy
CVV No.
- - -
Date of
Birth dd/mm/yyyy
Thanking you
(Signatures)
Name
Email address
Full Postal Address
Date
