Mail Order Form – La Mer Comfort

Card Holder

Name Surname

Credit Card Number

Exp. Date

CVV

Payment total

Reference

Customer Address

Date

Exit Dokuma San. Inc. I agree to charge the above amount from my declared credit card in return for the service specified with the reference mentioned above. If my debt cannot be collected due to the cancellation of my credit card or for any other reason, I undertake to make the payment using a different payment method. With this approval, I have signed and accepted the form.

DOSAB MUSTAFA KARAER CD. SARMAŞIK SK. NO:8 OSMANGAZİ, BURSA / TURKEY

T: (+90) 224.261.3231 F: (+90) 224.261.3236 E: exitdokuma@gmail.com