AU00833
FINFM0010
Issue 4.3 – 14 JAN 09
Transaction Details:
1. Payment Type
EFT Cheque
For Cheques please allow a minimum two working days clearance
2. Payment Type
Visa
3. Card Number
5. Expiry Date
M/Card Amex
4. Credit Card
Verification
Last 3 digits from the back of the Credit Card
6. Name On Card
7. Company or
Business Name
Transaction Amount:
9. Amount $
Transaction Authorisation:
10. Signed
Signed
11. Date
12. Direct Deposit Details
Account Name for Funds Transfer (EFT):
BANK:
BSB:
ACCOUNT NUMBER:
REFERENCE NUMBER:
QUIRKS AUSTRALIA
WESTPAC ROYAL EXCHANGE SYDNEY
032-002
428736
ACC:_______________/O/N:____________________
Please ensure you quote your reference number when making your payment.
To meet delivery date _____________ please ensure payment is made ________________ (COB)
For EFT Transfers: Please email copy of remittance advice with your Co Name and Invoice Number or Order
Number to AUS.Quirks.Credit@anz.ccamatil.com
or fax on (02) 8805 2542
Office Use Only:
Quirks Officer Name
Date
Quirks Australia Pty Limited
ACN 109 670 948 ABN 81 109 670 948