[ucs]

You’ve just described e-commerce circa 1990!

On Usenet newsgroups and BBS conferences, sellers would post forms that looked exactly like that, except for the ads of course. Buyers would then send in their completed order form via either email/netmail or, preferably, via fax for added security.

I remember always choosing to fax in my orders; even way back then, sharing credit card details via email seemed like a very bad idea.