MERCHANT NAME & CODE
TRXSER NO.
TERMINAL NO.
CARD HOLDER
CARD TYPE
EXPIRY
DATE/TIME
APP CODE
TERMINAL TRACE NO.
SALE
CREDIT
ACCEPT
REVERSAL
TRANSFER
PRE-AUTH
AMOUNT
TIPS
TOTAL
ID.NO.
CARDHOLDER SIGNATURE
REFERRAL

CASHHOLDER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREON AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH IN THE CARDHOLDERS AGREEMENT WITH THE ISSUER.