Aldacom GmbH
Hans-Boeckler-Strasse 16
63263 Neu-Isenburg
Germany
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CREDIT CARD
PAYMENT FORM (All fields needs to be filled in)
Fax +49
–(0)6103-37214119
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Company name:
Country:
Contact person:
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Telephone number:
Fax number:
Email address:
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VAT registration number:
(only for companies within the
EC European Community)
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Card name (Visa or Master Card):
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Card number:
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Name of cardholder:
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Expiry date:
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Security number:
(3 last digits on the back of
the card where the signature is. This is mandatory.)
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Amount authorised:
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Cardholder signature and date:
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