| To: | I-CubeX Online Store | Fax Number: | Please email |
| Subject | Credit card details for my order from I-CubeX Online Store |
| Please print this form from your browser, complete sections 1 and 2 and sign and date in section 3 before faxing to us: |
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| Section 1 - Your details: |
| Name: | |
| Address: | |
| Tel: | |
| Email: | |
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| Section 2 - Credit Card details: |
| Order number: | |
| Currency: | CAD |
| Amount: | |
| Cardholders name (as it appears on card): | |
| Credit card number: | |
| Start date - if available: (mm/yy) | / | Expiry date: (mm/yy) | / |
| Security code: (3 or 4 digits) | | Issue number - Switch only: | |
| If you have any questions regarding the processing or storage of your credit card details please read our privacy policy or feel free to contact us. |
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| Section 3 - Signature: |
| Cardholders signature: |
| Date: | |
| PLEASE NOTE: Your order will not be processed or shipped until we have received your credit card details. |
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| Thank you for making your purchase from I-CubeX Online Store. |
Infusion Systems Ltd.
2033 Avenue de Vendome
Montreal, Quebec
H4A 3M4 CANADA
1 877 4 ICUBEX / 1 514 484 5850 |
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