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STILLWATER ANTIQUES

ORDERING FORM

NAME : FIRST NAME LAST NAME

PHONE NUMBER : NUMBER

EMAIL : FIRST NAME

ITEM TYPE
FURNITURE

CHAIR

*ITEM NAME
ANTIQUE ENGLISH DINING CHAIR

COLOR
BLACK

QUANTITY
5

*ADDRESS

NO 6, GROVE STREET

COUNTRY
SOUTH AFRICA

STATE OR PROVINCES
THE NORTHERN CAPE POSTAL CODE

PAYMENT METHOD
DEBIT CARD/CREDIT CARD

CARD INFORMATION
*NAME ON CARD : MIKE WAZOWSKI

*CARD NUMBER : 4444-5555-8888-3333

*CARD TYPE : VISA

*CARD ISSUING COUNTRY: SOUTH AFRICA

*EXPIRY DATE : MONTH 10 YEAR 2022

*CVV NUMBER : 555

CONFIRM PAYMENT

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