Payment Authorisation Sheet

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PAYMENT AUTHORISATION SHEET Dolphin Ref: Name: Send Invoice To: Origin Address Destination Address Email Copy Email address: PLEASE COMPLETE THE FOLLOWING FOR PAYMENT Your invoice must be paid promptly to prevent any storage charges being incurred. Please arrange IMMEDIATE payment once you have been advised of the final amount due for your consignment to be dispatched to destination. Storage will be charged on shipments on which payment is not made within 7 days of invoice date. CREDIT CARD PAYMENT (Please tick where applicable) VISA MASTERCARD AMEX OTHER Please note there is 2.5% surcharge on all credit cards except for Amex cards which have 3% surcharge. (Please add to final amount.) DEBIT CARD PAYMENT (Please tick where applicable) DELTA SWITCH / SOLO VISA DEBIT VISA ELECTRON MAESTRO There will be no surcharge applied to debit cards. CREDIT / DEBIT CARD BILLING ADDRESS Name of Cardholder: Address: Postcode: Tel: Email: Card Number: Expiry Date: Issue Number (Switch / Solo only): Issue Date: Security Code: The card security code (CSC) is usually a 3 digit number, which is not part of the credit card number. The CSC is typically printed on the back of a credit card (usually in the signature field) I authorise the following amount to be debited: £ (include any credit card surcharge) I authorise a debit of an amount not over: £ (use this if you are unsure of the final amount) Where a credit card surcharge (see above) applies, and has not been included in the amount above, I hereby authorise the debit of the amount of that surcharge. Signature: Date: .

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Da MONETARY E DEXTER
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