Acceptance of transaction

 

Billing Information:

 

 

The Credit Card Holder Name:

(First/Middle/Last)

 

 

 

Billing address:

 

(Address, City, State, Zip,  Country)

 

 

 

 

 

Delivery address:

 

(Address, City, State, Zip,  Country)

 

 

 

 

 

Phone:

 

E-mail:

 

 

Establishment:

 

ART MASTER Gallery

Liliova 6, 110 00 Prague 1, Czech Republic
phone/fax:+420 2 222 22 167, mobile: +420 777 082 645

e-mail: artmaster@inmodern.com,  web: www.inmodern.com

 

Description of goods

Quantity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total value:

_______,00 _____

 

Type of the card:

 - VISA

 - Eurocard/MasterCard

 

     

card number:

 

valid from:

 

 

security code of the card:

 

expiration date:

 

security code: Required for all Mastercard and Visa purchases

three-digit number, which is on a signature strip on the back side of the credit card next to the card number, respectively next to the last four-digit number of the card number.

 

Valid form of identification:

 - Driving license

 - Passport

 - Social security number

number:

 

 

 

I accept the charges to my account with the following amount of _______,00 _____.

  

 

Date: _________________      Signature of the credit card holder:

 

 

 

 The debit will appear on your credit card statement as ART MASTER GALLERY