MOTO Charge Form

Name On Card (required)

Your Email (required)

Your Phone Number (required)

Order Reference (required)

Card Number (required)

Card Expiry (required)

CVV number (required)

Bank (required)

Card Type (Visa/Master/AmEx) (required)

Invoice Amount (required)*

Special Notes

I hereby authorise Kangen International to charge my credit/debit card specified below of the specified invoice amount

*Please note that final charged amount may differ marginally due to fluctuations in foreign exchange currency rates