Please Print out the following form and fax it to us at +(6638) 710276
 
 
My details as provided to the credit card company are as follows:
Name
__________________________________________________
Address
__________________________________________________
__________________________________________________
Email
__________________________________________________
Telephone
__________________________________________________
Fax
__________________________________________________
Date of Birth
________________________________________[dd/mm/yyyy]
 I hearby authorize New Esquire Tailor to deduct an amount of   US$________________ from my credit card.
     
Credit Card
American Express Master Visa
Card Number
__________________________________________________
Card Verification Code
__________________________________________________
Card Expiry Date
__________________________________________[mm/yyyy]