Credit Card Secure Payment Fax Form

  

Please print this form, ensure that it is filled out completely, and fax it to
Olima Co., Ltd.: +66(0)53-405299 replace + with your country's or provider's international dialing code. Omit the (0) if you are faxing from outside Thailand

I authorize the charge of ______________ (amount)
_____ (currency) to my

Mastercard Accepted MastercardVisa Accepted Visa JCB Accepted JCB

I accept to pay the balance of________________(amount)
_____(currency) on (dd/mm/yy) ___/___/___

 Payments are credited to our Thai account in Thai Baht (THB). Charges should appear on your credit card statement in your local currency based on the exchange rates and according to your card-issuer's policies. 

Cardholders Name:
(exactly as it appears on card)

 

Card Number:
        -         -         -        

Expire Date:

Month:

 

Year:

 

Security Code: 
 
The last three-digit number appearing on signature panel - MasterCard/Visa

Cardholder's Billing Address:
Building:
Street:
District:
City:
State/Province:
Zip:
Country:

Passport Number & Nationality:

 

E-mail Address:

 

Telephone Number:
Area code:
Number:

Fax number:
Area code:
Number:

Booking ID:(please refer to the E-mail messages your received from us)

 

Name of the Hotel:

 

by signing this form you agree to the charges above and declare that all details are correct and that this credit/charge card belongs to you.

Signature: 
(as it appears on card)

 

Please print this form, fill it out completely, then fax it to Olima Co., Ltd., +66(0)53-405299