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1. (street address Costa Rica) ____________________________
2. Name to accept mail in: _____________________
3. Code word or Number for future instructions ______________________________________
4. Name to forward mail to you: (Please note. One personal name & one Company name is acceptable in most cases. See each country as we may be able to arrange mail in unlimited names). _________________________________________________________________
5. Address: _________________________________
6. City & Postal Code: ________________________
7. Country: _________________________________
8. Special Instructions: ___________________________________________ ___________________________________________
9. Payment Method: Type of Credit Card [ ] Visa [ ] MasterCard [ ] American Express [ ] Diner Club Name as it appears on credit card : ___________________________________________
Billing address: _____________________________ ___________________________________________
Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Credit Card ID Number (4 Digits of upper on front of card for AMEX, 3 digits on upper right in back for VISA/MC _ _ _ _. This is required to authenticate your charge authorization. Thank you.
Expiration date _ _ / _ _ _ _
Charge my credit card (don't forget postage deposit plus 5% for CC surcharge.) Add 10% on all VISA CC orders.
US$ ______________________________________
Signature: __________________________________
We also accept payment by Western Union Quick Pay; and .
Please INCLUDE your e-mail address or fax number in case we need to contact you regarding this order. Thank you ______________________________________________________ |