Fax  order

To: Brandy  Direct	VAT no: 620 9620 57
13 Westbourne  Place							   Tel - 01273 749758
Hove									   Fax - 01273 203418
East Sussex
BN3 4GN									   Date :	

Please supply:

           Quantity			type		              price each			value





















































Customer  name:

Address:     					Delivery address (if different):




Telephone number: 									

Credit card details: mastercard   visa   switch   solo 

Cardholder account number: 

Name and initials exactly as they appear on the card: 

Valid from date ( if shown ): 

Card issue number (if switch or solo): 

Card's 'expires end' date: 

Statement address: 

Contact phone number (if different from above): 

Cardholder's  signature: