Raja's International Custom Tailors - Payment Authorization Form

LETTER OF AUTHORIZATION

Yes! I WOULD LIKE TO PROCEED MY ORDER OF CLOTHES/ CATALOGUES FROM RAJA'S
INTERNATIONAL CUSTOM TAILORS.

	NAME
	ADDRESS
	Line 1
	Line 2
	COUNTRY
	PASSPORT NO
	TEL	FAX

I, HEREBY AUTHORIZE RAJA'S INTERNATIONAL TAILORS TO DEDUCT THE SUM OF
US$ FROM MY CARD.

CARD NUMBER
Four Digit Code (In case of American Express Only)

VALID UNTIL (MM/YYYY) DATE (DD/MM/YYYY)

.......................................................................................
SIGNATURE AS ON CREDIT CARD
.........................................................................................
ORDER ONCE PLACED CANNOT BE CANCELLED

PLEASE DELIVER MY GOODS/ CATALOGUES TO
(Leave blank if address same as above)

NAME

                        ADDRESS

COUNTRY

TEL: FAX:

Due to security reasons we do not accept the Credit Card
Information over the web.

PLEASE PRINT THIS FORM & FAX THIS TO:

Raja's International Custom Tailors
FAX:(662) 254'3513