Reloadable debit card - Order Form

Ordering by unit:

Quantity	Price per card
1 Card	US $180.00
2 to 20 Cards	US $170.00
21 to 49 Cards	US $160.00
50+ Cards	US $140.00

Quantity	Description	Price per card	Total price

1x	International Courier (DHL,FedEx...)		100 USD

TOTAL PRICE

Payment methods:

InternationalBank Transfer (Wire, Swift, etc.). Timeframe to receive your payment: 72H-120H	Certified cheque Timeframe to receive your payment: 22 business days

You would like to pay your order by bank transfer: All transaction costs and fees must be paid by you (remitter).

Contact details and shipment address:

*First Name:
*Last Name:
Company Name:
*Address:
*City
*State/Province:
*Postal/ZIP code:
*Country:
**Phone:
**Fax:
*E-mail:

*REQUIRED

** Phone or Fax required for DHL delivery purposes

Referral method:

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