Credit Card Confirmation Form

Please print this page, fill in
the form, and fax to:
+66-53-232300

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Date: ............................................................
To: Travel Shoppe Ltd. Part.
Attn: Management
Fax: +66-53-232300

Credit Card Information
Card holder's name: ................................................................................
Credit card number: ................................................................................
Date of expiry: ......................./........................................................
Credit card type*:
 Visa
 Mastercard
 American Express / Card Code: .................... (4 digits)
Email address: ................................................................................
Authorized to charge: ................................................................................


................................................................................
Card holder's signature