CARD HOLDER COPY

MERCHANT NAME & ID

SETT. DATE

TERMINAL ID

OPERATOR ID.

ISSUER BANK

ACQUIRER BANK

CARD NO.

TRANS TYPE

AUTH NO.

BATCH NO.

VOUCHER NO.

DATE/TIME

EXP DATE

SYS. REF. NO.

PRINT FLAG

AMOUNT

ORIG. VOUCHER NO.

REMARKS

I ACKNOWLEDGE SATISFACTORY RECEIPT OF RELATIVE GOODS/SERVICES

CARDHOLDER SIGNATURE

THE ISSUER OF THE CARD IDENTIFIED ON THIS ITEM IS AUTHORIZED TO PAY THE AMOUNT SHOWN AS TOTAL UPON PROPER PRESENTATION. I PROMISE TO PAY SUCH TOTAL (TOGETHER WITH ANY OTHER CHARGES DUE THEREON) SUBJECT TO AND IN ACCORDANCE WITH THE AGREEMENT GOVERNING THE USE OF SUCH CARD.

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