CREDIT CARD PAYMENT AUTHORIZATION

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

(please indicate currency)

amount in words

To My Credit Card: Visa Card
 Visa		  Master Card
 Master Card		 American Express
Amex 		 JCB
 JCB 		 Siam Commercial Bank
 SCB
My name as appear on the card is :
Card Number :               Expiry Date :
Bank which issued your credit card :     Country :
Please fill in the last three-digit number (for VISA card) or four digit number (for AMEX) appearing on signature panel: (see example)

The above mentioned charge is for :

Flight Routing :    Departure/Arrival Dates:
Passenger Names :
Card Holder’s Signature :
_________________________
 
Date:
Cardholder's Nationality:
Cardholder's Passport No :
Cardholder's Billing Address :
Cardholder's Tel. No : Country Code   No
Cardholder's Fax No : Country Code   No
Cardholder's E-Mail :
If Travex Co., Ltd. is unable to process my payment, I will be responsible for an alternative payment arrangement and any resulting processing fees.
 
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)