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

CARDHOLDER 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 CARDHOLDER’S AGREEMENT WITH THE ISSUER.