Credit Card Purchases (Books and DVDs), Donations and Membership.  Fax authorization to debit your credit card (Visa and Mastercard) 

Print the page and fill out the information requested in the form on the printed copy.
Fax the page, with your credit card details and signature to the Centre for Research on Globalization. Fax number: 1-514-656-5294.
Your order will be processed within two business days.

NAME IN FULL AS IT APPEARS ON YOUR CREDIT CARD

………………………………………………………………………………..
ADDRESS AS REGISTERED WITH YOUR CREDIT CARD (including postal code)

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(Street and No)

…………………………………………………………………………………   
(City, State/Province. Area Code, Country 

Tel number (indicate country and area codes) ……………………………… Email:………………………………. (tel /email for followup only, remain confidential)

Indicate the address where you wish your order to be shipped (if different from above, otherwise leave blank)

…………………………………………………………………………………
(Street and No)

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(City, State/Province. Area Code, Country 

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CREDIT CARD NUMBER

…………………………………………………….. (3 digit number security code on back of card) …….. 
EXPIRY DATE (mm/yy)
Visa or Mastercard (V or M)……..  (unable to process Amex)

For the purchase of (indicate the item or items purchased, books or dvd).

1…………………………………………………………………………………

2…………………………………………………………………………………

3…………………………………………………………………………………
Indicate total amount US$……………………  (Total of all purchases plus s and h charges, to be added to your order. Include airmail surcharge if applicable. See online store for details)

If Donation and/or Membership (annual)………………………………………. (specify and indicate amount) US$………….

I hereby authorize the Centre for Research on Globalization (CRG) to debt my credit card.

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Signature and Date