Payment
   
Authorization Form
I would like to proceed with my order of clothes from
MR. BOSS
 
   
FULL NAME :
PASSPORT NO :
STREET :
CITY :
COUNTRY :
PROVINCE/STATE :
POSTAL CODE :
TEL :
FAX :
E-MAIL :
 
   
  I authorize MR. BOSS to
 
Deduct the sum of:
 
From my Credit Card :
Card Number :
3 or 4 Digit Code:
Click for help
Diner 2 Letters:
Expiry Date :
(MM/YY)
   
 
 
   
Ú................................................................. (Orders once placed cannot be cancelled)
Signature as on credit card Date
   
   
 
 
  Please deliver my clothes to ( Leave blank if address same above )
 
   
FULL NAME :
STREET :
CITY :
COUNTRY :
PROVINCE/STATE :
POSTAL CODE :
TEL :
   
 
 
  After Printing, Sign & Fax us this form
   
 
 
  MR. BOSS Telephone : +(662) 629-0481