order form

For MasterCard users only

(Fax No.: +961 4 419 724)

Dear applicant, please write in BLOCK letters. Date .......................

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Full Name: ...........................................................Date of Birth: ........................................

Company Name: ................................................................................................................

Type of Business: ...............................................................................................................

Address: ............................................................................................................................

P.O.Box: .........................................Tel: .............................................Fax: .......................

1. ............................................................................................Amount (US$) ......................

2. ............................................................................................Amount (US$) ......................

3. ............................................................................................Amount (US$) ......................

MASTERCARD

Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CVC2 ( )

Date of Issue: .......................................................... Expiry Date: .........................

Issued by: Bank Name: ........................................................................

Country: ..............................................................................

Merchant name ....................................Merchant Number...........................................

I, the undersigned, hereby certify that all the information given in this application is true and correct to the best of my knowledge.

........................... ...............................

Date Signature

I, the undersigned,........................................authorize ..................................

To bill my invoice to my MASTERCARD No: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Without my prior consent, for an amount of (US$) .........................

This request is accepted by me and can’t be revoked.

........................... ...............................

Date Signature

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For FRANSABANK use only

Amount reserved ......................Authorization No. ........................Date ..............