CREDIT CARD FAX FORM

 

Date: ______________________________

 

To:

Phil Travel Service Pty. Ltd. 105 Pitt St. Sydney 2000 Australia

Ph. +612-92325677 Fax +612-92353142 email: info@airdiscounter.com

Dear Sir/Madam,

Re: Authorization for charging my travel expenses on Credit Card.

Please charge my credit card: AMEX/DINERS/MASTERCARD/VISA

Card holder's name:__________________________ Title:MR/MRS/MISS/MS___

Expiry date:_______________ Card Number:_______________________

Security Code:___________

The amount of (Australian Dollars) AUD____________

In words:_________________________________________

Payment for: Insurance/Airline tickets/Others(____________________)

Name of passenger(if different from cardholder)____________________

___________________________________________________________________

___________________________________________________________________


Signature of cardholder:_________________________

(must be same as on the creditcard)

Billing address of cardholder:___________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Forwarding address(If different from above):_______________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________