ULTIMA TRAVEL
Credit  Card Payment Authorization - Fax  Form

Please print this form, fill  it out completely, and fax it to any of the following  ULTIMA T&T fax numbers: +66-2-2546079, +66-2-6538152

I  hereby authorize ULTIMA T&T Co., Ltd., Bangkok, Thailand to charge   _______ US$

(_____________________________________________________________US$only***) 

to my  *AmericanExpress*  * Visa *  MasterCard *  *JCB*  (circle  one)  credit  card.

Cardholders Name:
(as it appears on  card)

 

Guest's  Name:
(if different from above)

 

Card  Number:

 

Expiration Date:

 

Cardholder's Address:

 

Passport Number:

 

Nationality ( as in Passport ):

 

E-Mail  Address:

 

Package Tours & Dates:

 

Signature:
(as it appears on  card)

 

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@2005-2006 Ultima T&T Co., Ltd., Bangkok, Thailand