CREDIT CARD PAYMENT AUTHORIZATION

I,   authorize Travex Co., Ltd. of 86 Soi Langsuan, Ploenchit Road, Bangkok 10330, Thailand.
to charge the sum of :

(please indicate currency)

(in letters)
TO: Visa Card
 Visa		  Master Card
 Master Card		 American Express
Amex 		 JCB
 JCB 		 Siam Commercial Bank
 SCB
Card Number :               Expiry Date :
Please fill in the last three-digit number (for VISA card) or four digit number (for AMEX) appearing on signature panel: (see example)

My name as appear on the card is :

The above mentioned charge is for :

Card Holder’s Signature :
_________________________
Date:
Cardholder's Passport No :
Cardholder's Address :
Cardholder's Tel. No : Country Code   No
Cardholder's Fax No : Country Code   No
Instructions on How to Use This Form:
1) Kindly fill your credit card type, card number, name on card, expiry date, plus the last 3 or 4 digits on the back of your card (depending on your card type)
2) Print out the form and verify that all details are correct, then please sign your name on the "Card Holder's Signature" line
3) Fax authorization form, along with copy of the credit card on both sides to Travex Air Ticketing Dept at: (662) 652-1033
4) Please also fax a copy of passenger's passport (the page with picture and passport holder information)