CREDIT CARD INFORMATION FORM

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Credit card information form to be sent by fax to +40-21-316 10 84

Valid only for VISA CARD and MASTERCARD if payment is in USD.
For Romanian LEI payments, only VISA CARD is valid.

At ICI location, with your card in hand, we accept Visa, Mastercard,
Maestro and Visa Electron cards.

1. List of domain names/IP addresses to be payed: ______________________

________________________________________________________________________

2. Date of sending the domain name/alocate IP addresses registration 
application: ___________________________________________________________

3. Email address from where the application was sent: __________________

4. Credit card type (Visa, Mastercard) _________________________________

5. Last name and first name of the card owner, as shown on the card

________________________________________________________________________

6. The birthday of the card owner_______________________________________

7. The card number is: _________________________________________________

8. The expiry date of the card is: Month:_____________ Year: ___________

9. The address of the card owner is:

No. and Street: ________________________________________________________

Address continue: ______________________________________________________

City: __________________________________________________________________

State/Province: ________________________________________________________

Country: __________________________ Zip/Postal Code: ___________________

Telephone (mobile number is not valid): ________________________________

10. Name of the bank issuing the card: _________________________________

11. Amount of the payment ________ USD/EUR

12. Identity Card Number / (driver license for US)______________________

13. Personal Registration Number / Social Security Number_______________

14.Copy of the card (Both sides, to show card number and your signature)

15.Copy of your Identity Card

16.Print Name: _________________________________________________________

17.Signature: __________________________________________________________


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