Tsuei Ma-Ma Foundation
Credit Card Payment Authorization Form

※Note: A Cardholder is required to fill out this form.※

Name		ID Number
Phone No. Must be filled in	day:_____________ evening:____________ cell/mobile:____________
Information Resource	□ Internet　□Email　□ Friend　□ Other:__________________
E-Mail
Types of Invoice	□2 Copies（Person） □3 Copies：Invoice Title：___________　Tax ID No.：___________
Billing Address Must be filled in
Credit Card Payment Information：
Type of Card	Issuing Bank：___________ Bank □VISA　□Master　□JCB
Card No.：		Expiration Date：to______(year)____(month)
Signature：（Must match signature on the back of the card）		Payment’s Date：___ year)___(month)___(day)
Amount：NTD_________________________
□ Member’s Continued Purchase □ Donation ※New members shall not fill in this form. Please contact TMM first.
Authorization Code（please don’t fill in）：
CARDHOLDER AGREES TO PAY ABOVE AMOUNT TO ISSUE BANK ONCE BUYING THE GOODS ACCORDING TO THE STIPULATION OF CREDIT CARD
■ Add: 2F, No.2-3, Lane 269, Sec. 3, Roosevelt Rd., Da-an District, Taipei 106, Taiwan106 ■ Tel:（02）2365-8140, extension 133~139 ■ Fax: (02)2368-3073 ■ E-mail：tmm2.org@msa.hinet.net ■ URL：http://www.tmm.org.tw/