CREDIT CARD PAYMENT FORM

AVARDS SUPERMOTO PROMOTIONS

PAYMENT BY CREDIT CARD.

Please accept this payment as my entry fee for the Supermoto event.

I have emailed my entry form.

Riders Name:

Date of Meeting:

Entry Fee: $

Credit Card Details:

Type of Card:

Mastercard / Visa /Other..............

Please note no American Express

Card Holders Full Name:

Card Number: ........... ........... .......... ............

Expriy Date: ........ / ........

Card Holders Signature:

Please print off and fill out then FAX to 02 49 96 31 20