Automatic Credit Card Payment Authority

To:     

ABN 87 053 498 285

COOROY    QLD    4563

Phone:         5447 7577

I/We authorise Cooroy Mountain Spring Water to debit amounts owing by me/us on a monthly basis for goods and services rendered or invoices by Cooroy Mountain Spring Water.

Please charge purchases to my credit card account.

Bankcard

Mastercard

Visa

Amex

Card Number:

Cardholder Name: __________________________________________________

Expiry Date: ___________________________

Security Code: ________ (This is the last three digits on the back of the card where you sign)

Address: __________________________________________________________

              _____________________________________________

              _____________________________________________

Phone Number: _____________________________________________________

Signature: _________________________________________________________

Date: ________________________

For the convenience of automatic credit card payments please complete this form and send it back to us.

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