Credit Card Payment Form

Please print this page then fill in all the requested information and fax to Fire Busters at 604-599-4319. If you have any questions, please contact us 604-599-4499 or email us.

PLEASE NOTE: Name, Address & Postal Code MUST match EXACTLY as per credit card statement from your bank or financial institution!!

Card Holder Name:_____________________________________
(Must be exactly as per credit card)

Address:_____________________________________________
(Must be exactly as per credit card statement)

City:________________________________________________

Province: _B.C_____________ Postal Code:_________________

Phone:_____________________ FAX: _____________________

Payment to account of :_________________________________

Payment Amount: $____________________ Canadian Currency

Type of Credit Card:     Visa    or     Master Card

Credit Card #___________________________________________

Expiry Date:____________________________________________

I Authorize Fire Busters Inc. to charge my credit card for the amount indicated above.

__________________________________
Signature of Card Holder

_____________________
Date