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 5000/= (Rupees Five Thousand
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
