This is not a secure form. For your protection please print out the form and fax to 00 27 11 469 3199
If you do not receive a response within 48 hours please e-mail us. (
gullwing@iafrica.com
)
Please use a black pen only for legibility reasons
Currency =
£
Euro
USA $
Aust $
ZAR R
Card:
Master
Visa
Amex
Diners
Amount:
Card No:
Exp date:
CVV no:
(last 3 digits on reverse of card):
ID No:
Name and Address:
Title:
Name:
Surname:
Full delivery address:
Area code:
Daytime Telephone No:
E-mail:
Specify the model, approx year and make of your car required:
1st Choice:
2nd Choice:
Methods of payment:
Credit card:
Internet transfer:
Moneygram:
Signature:
Place your order now by fax:
Fax to: 00 27 11 469 3199; Phone: 00 27 11 469 3198; Galleria Interior Lifestyle;
P O Box 784935
Sandton Johannesburg South Africa 2146