South African orders ONLY
FAX and electronic payment orders
FAX TO 086 542 0381

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 it to us and tick the EFT payment block below and please use your Cell Phone number as Reference when transferring money and mail the proof of payment to orders@ageless.co.za or fax the proof of payment to us. Our bank details...

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

       

-

       

-

       

-

       
 

CCV number of credit card (see information...)

 
 

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