Gas Appliance

Payment Details - Fax or Mail Order

This form may be used in the following way with Fax or Mail orders -
  • Print blank copy, complete relevant boxes manually, then fax/post
  • Complete relevant boxes, print completed form, then fax/post
  • Remember - fax or mail copies must be signed by Cardholder

Ref: Order Number

Please enter details below

Card Type

Name of issuing Bank

Card Number

Card Issue Number*

*Start Date/Issue Number - Switch and Solo Cards only

Cardholder's Name (as it appears on card)

Card Expiry date

Security Code (Last 3 digits on signature strip)  

Cardholder's full postal/billing address

Delivery address (if different)

Cardholder's Signature