DATE : ____________________

GALLERY 278 PRIVATE LIMITED

278 RIVER VALLEY ROAD • SINGAPORE 238319

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RE : AMERICAN EXPRESS CREDIT CARD AUTHORISATION

FULL NAME

 

 

POSTAL ADDRESS

  

 

EMAIL ADDRESS

 

 

TELEPHONE NUMBER

 

 

FAX NUMBER

 

 

I ______________________________ (Full Name) on this __________ day of  _______________ 20____, do hereby irrevocably authorise Gallery 278 Private Limited to debit my American Express credit card with the amount of S$____________________ being payment made for ______________________________.

NAME (AS PRINTED ON CARD)

 

 

CARD NUMBER

 
4 DIGIT IDENTITY No. _________

EXPIRY DATE

 

 

Sincerely yours,

 

__________________________________________

(signature as on card)

Please write in block letters and fax to us at (65) 6737 0322.

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