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                     棋侶空中棋社信用卡專用付款證                             

AIRGO SUBSCRIPTION/PAYMENT FORM

 □ 1. 我想支付「說棋講弈+空中圍棋 年費」(Payment for Airgo Member Fee for     1000元       。

 □ 2. 我想支付「棋侶道場+空中象棋 年費」(Payment for Airgo Member Fee for     1000元        。

 □ 3. 我想支付「棋侶兒童圍棋學苑 年費」(Payment for Airgo Member Fee for     1000元        。


※ 網站會員帳號( user ID )：                                  。
    (  請填寫您在「說棋講弈」或「棋侶道場」或「棋侶兒童圍棋學苑」中的會員帳號，以利工作人員將其昇級為年繳會員  )


選擇用信用卡付款(Charge my □VISA　 □MASTER　 □AMERICAN EXPRESS)

發卡銀行：                                                

信用卡號(Card No)：            -            -            -           

信用卡有效期限(Expiry Date ：           年(year)           月(month)

卡片背面簽名欄數字後三碼(3-digit number on the card signature panel) ：                    

訂購日期(Date of Payment/Purchase)：                                            

付款總金額(Total amount)：                                                   

持卡人簽名(Signature):

　                                                                                     

付款人(棋友)姓名(customer name):                                                                   

收件地址(delivery address)：                                                                   

聯絡電話(Telephone no):                         (Office)                         (Home)