Payment by credit card information by fax

[Mad_rock]

I need a payment method;
When the customer choose it, a payment form will be created that includes empty lines for credit card information (card number, expiration date, ccv) total price will be filled automatically. The customer will print this form, fill the card info and sign. After this process, the customer could send it by fax or scanned form by email.
Is there an extension or is it possible to develop it easily.

[GJC Web Design]

Either a standard form component with some parameters passed to it from a simple payment plugin .. my current favourite is RS Forms  or perhaps have a look at Alataks off line CC payment

http://extensions.virtuemart.net/checkout/payments/offline-credit-card-processing-detail