Czech ladies - Secure Credit Card Charge Form

The information you submit here is 100% secure. It will be only transmitted encrypted. Guaranteed.
Your full name:
The name on the card: (only if different from above)
Credit card number:
Card ID (CVV2/CVC2)	There is no CVV2 code on the card
Credit card expiration date:
Credit card billing address: (the address where you receive this credit card's statements)
Your telephone number:
Is this number:	home work cellular
Alternative telephone number (optional):
Is this number:	home work cellular
Your email address (optional):
Your order number: (if you don't have your order number, make sure your name and email address are on this form)
Amount: (Optional. If you know the amount of the charge)
Comments: Your notes or comments about this payment (i.e. what is it for)

	By signing this form I authorize the company "" to debit my credit card the amount of US dollars for the above order.
	The prices for credits are the following: 12 credits - $20 60 credits - $60 105 credits - $100 320 credits - $300 550 credits - $500

Global Services and Outsourcing Ltd International House, 776-778 Barking Road London E13 9PJ, United Kingdom