Dear Customer:

For your convenience Eshabeta II will accept:

Payment method: _______________________

Credit Card No.  _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _

Expiration Date: _ _ / _ _ _ _ (month/year)

Amount US Dollars: $____________

Authorized Signature: _________________________

Date: _________________

Please Print Name: _____________________

Address: _____________________________

____________________________________

Phone: __________Work/Cell: ____________

 

Important Note! - A photocopy of the credit card being used and current driver’s license is required.