American Express Card Payments

The Form is intended for payment of CO.ZA Legacy Domain Names. Please complete this form Online and Click on "GENERATE FORM" at the bottom of the page. The completed Form will be displayed ready for printing. When you have printed the completed form, then please sign it and Fax the Form to Uniforum SA FAX # +27 11 314-0088

Cardholder's Name:

Cardholder's Phone Number:

Card Number:

Card Type:

American express

Expiration Date:

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15

Amount paid:

R

Invoice Numbers or Domains paid for:

OR