Payment



75 Soi Phayamonthartrajsripijit, Kwang Bangbon, Khet Bangbon, Bangkok 10150 Thailand

Tel	:	(662) 8998611-5

Fax	:	International(662) 4157395 Domestic(662) 4157396

E-mail	:	micro@microemb.com

Note: To secure your credit card information, you can print out this form with all the information besides the credit card details. Then you can fill out the credit card details and fax it to us. Thank you.

:: Payment Form ::

:: Privacy Statement ::

1. Customer Details :

Company Name	:
Address 1	:
Address 2	:
State	:	Zip	:
Country	:
Tel	:	Fax	:

2. Credit Card Payment :

Amount in words	:
Amount in No.	:
Card	:
Credit Card Number	:
Card Holder Name	:
Card Holder's signature	:
Submit Date	:
Expiration Date	:

3. Payment Details :

Invoice No.	:
Invoice Date	:

:: Privacy Statement ::

75 Soi Phayamonthartrajsripijit Bangkhunthien Rd.,Bangbon Bangkok 10150 Thailand
Tel : (+662) 8998611-5, Fax : International (+662) 4157395, Domestic (+662) 4157396
e-mail : micro@microemb.com