| NEW
CUSTOMER DETAILS
| Today's Date: ................................................... |
| Passenger's Name:............................................................................... |
| Passenger's email Address:.................................................................. |
| Passenger's Mobile
Phone: .................................................................. |
| |
PAYMENT
DETAILS |
| |
| Date to Commence: .......................................................... |
| Credit
Card Details: |
|
|
|
|
Visa |
Mastercard |
| Card Number: |
|
| Expiry Date: |
|
CCV Number
|
|
on rear of card |
| |
| |
| I ............................................
authorise Bankstown Coaches to deduct the sum of |
(Print name) |
|
|
|
|
|
| $280.00/ $340.00* from
the nominated account above. *Cross out
which does not apply. |
Signature of Cardholder
....................................................................................................... |
| Just
print - complete - and fax to (02) 978 66407 |
