Full name:
Address: 
City:
State/Zip:
Country:
Home phone:
Business phone:
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P. Lal Store (est.1929)
2-1-3 Woodlands Apartment
2 Pekarangan Tun Ismail
off Jalan Tun Ismail
Kuala Lumpur 50480 
Malaysia
Tel: 603 2694 2694 Fax: 603 2697 2697

Date:

Dear Sirs,

Re: Mail order purchase of 1 pair(s) of shoesCrockett & Jones - M$
Airmail shipping to 
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I hereby authorise you to irrevocably debit M$1499.00 to my credit card account details of which are:

1. Visa/Master
2. Issuing Institution:
3. Card no.:
4. Expiry:
5. CVV2 no.:
6. Name as embossed:
7. Billing address:
8. Billing phone no.:

I agree to be responsible for to & fro shipping charges should I for any reason require an exchange of goods or a refund.



.....................................
Signed with signature as on your card.
Date: