| Cardholder's
name___________________________________________________________ Passport
Number___________________________________________________________
Billing Address :
_____________________________________________________________
__________________________________________________________________________
Country :
________________________ Zip Code : ________________________________
I hereby authorize
Ruk
Talay Travel Co.,Ltd. to charge:
Amount in US$
___________________ or in Thai baht ______________________________
( ) Visa Card ( )
Master Card
Card Number
:---- ***
***The Last three digit number appearing on the signature
panel
Cardholder's name ( as
appears on credit card )__________________________________
_______________________________________________________________________
Expiry date ( dd/mm/yy
) ____________________________________________________
Comments
:____________________________________________________________
______________________________________________________________________
Signature of
Cardholder: ___________________
Date :
___________________
|
