Credit Card Payment Authorization
Form
To: (86)28-87562424
Access
Tashidelek, subsidery No. 1,
No.41
From: ________________________________________
( Your Full Name)
Billing Address: ______________________________________________
(Street)
______________________________________________(City, State, Zip, Country)
This is to guarantee my payment to ACCESS
TIBET TOUR after ACCESS TIBET TOUR has confirmed my booking for the requested
travel service.
To
the Bank of
I hereby authorize ACCESS TIBET TOUR,
to charge the amount of US$___________ from my Credit Card as my payment for my
tour to
.
Access Tibet Tour has a copy of my
card, the number and expiration date as detailed below:
Credit Card Type: _____________ Card
Holder¡¯s Name: _____________________
Credit Card Number:
_________________________________________________
(Please write it clearly)
Expiration Date (MM/YYYY): ______/___________
Card Holder¡¯s Birth date (MM/DD/YYYY):
____/____/______Nationality: __________
Issuing Bank of your credit card: ___________________________________
My
phone number: ______________________________
My
passport number: ______________
Your
Signature:
____________________________(Should be the same as on your credit card)
Note: The Bank of China requires a legible photocopy of both sides of your credit card. Please, send the copy (page 2) with this form.
Please fax it to: (86)28-87562424
Page 2 of 2
Please
make photocopies of the both sides of your credit card:
|
Copy of your
credit card (front) |
|
Copy of your
credit card (back) |
Please fax it to: (86)28-87562424
Please, fax this page with your
completed Authorization form. (Page 1)