Marty's Offline Fax Payment Form

• Full name*
• Mailing Address*
• Passport No.*
• Tel. Number*
• Fax. Number
• Email*

To Marty 's New Fashion

• I, Hereby authorize Marty's New Fashion to proceed with my order and to debit the sum of   Select US Dollars Baht     from my credit card specified below
• AMERICAN EXPRESS MASTER CARD VISA CARD

• For american express, please enter the 4 digit numbers appearing on the right hand corner of your card:
• For visa / master card, please enter the last 3 digit numbers appearing on the signature panel of your card:
• Signature : as on credit card:
  _____________________________________

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- Fill in the necessary information and then print using the print button below
- Fax the form to Marty's New Fashion at 662-252-6291
Note 66 is the country code for Thailand and 2 is area code for Bangkok.

Print Form