Elite Racing 12 months membership including Elite-Multi; faxed authority form

Order Form

Please print this form out then fill in the details and sign. Your order will be processed on receipt of this form.

Post to: Elite Racing Data Pty Ltd
PO Box 1345
Booragoon WA 6154

or: FAX (08) 9524 7633

To Elite Racing Data Pty Ltd:
Please supply the Elite-Multi Computer Program

Authority
I hereby authorise Elite Racing Data Pty Ltd to deduct from the credit card
(details below) $1290 being payment in full for 12 months Elite racing membership including the Elite-Multi
computer program

Visa / MasterCard / Bankcard Number: _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _

Expires:____/____ Name On Card:____________________________________

Cardholder's Signature:___________________ Date: _____________________

Name:__________________________________________

Address:______________________________________________P/Code________

Phone:________________________ Mobile: _________________

Fax:________________________ email:____________________________________________