South African orders ONLY
PAYMENT FORM

FAX and EMAIL of Payment, Credit Card and electronic payment (EFT) orders

FAX Number 086-542-0381 - Email orders@agelesshealth.co.za

CREDIT CARD
Please print out this page, fill in your credit card detail, order, sign and fax it to us.

ELECTRONIC PAYMENT
if paying by EFT (Electronic Fund Transfer) complete the order form and fax or email it to us and tick the EFT payment block below and please use your Cellphone number or Name and Surname as reference when transferring money and mail orders@agelesshealth.co.za or fax (086-542-0381) the proof of payment to us.  Our banking details are:  First National Bank, Sallamander Concepts, Branch Code 250-655, Account Number 62268080109 or see our details here

PRODUCT PAGE

Please debit my credit card

 

I will be transferring funds via EFT

 
 

Name as on card

 
 

Type of card (please circle applicable one)

Visa MasterCard American Express Diners Club
 

Expiry date

Month Year
 

Card number

       

-

       

-

       

-

       
 

Signature (as on card)

 

 

 

 

e-mail address

 
 

Contact telephone number (preferably cellular number...)

 
 

Delivery address - South Africa (see information...)

 
 
 

Postal code (we need it for courier delivery as well)

 

Item

Price

Total

 

R

R

 

R

R

 

R

R;

 

R

R

 

R

R

Delivery (Courier or Speed Services Counter-to-Counter) see options...

R 80.00

Total due

R