Fax Sheet
GillianCards - Wholesale
Fax to: (801) 720-5775



Please fill in ALL of the following information before faxing:

Company Name:

Name of Credit Card Holder:

FULL Address & Phone Number as shown on your credit card statements:

Street:

City/Town:

Apt. or Unit if applicable:

Province/State:

Postal Code/Zip:

Credit Card Company:

Master Card
Visa
Amex

Credit Card Number: ____________________________________

Date of Expiry:

Month ______ Year______

Security Code: (3 digits except for Amex which might contain more numbers)

_______