AMEX

AMERICAN EXPRESS CARD AUTHORIZATION FORM

To: American Express (Thai) Co., Ltd.

I, ..............................................................................................................................

Amex card holder number: ........................................................................................

hereby authorize A.T.N. Intertrade, merchant number 987 2757240 to charge

Baht....................................as full payment of.............................................................

..................................................................................................................................

( must clearly indicate name of travellers and flight / routing etc. )

My card expires on: ...................................................................................................

Security number (4digits) on card: ..............................................................................

Passport No: .............................................................................................................

Nationality: ................................................................................................................

My Amex billing address: ...........................................................................................

Phone number: ...........................................................................................................

Signature of card member : ........................................................................................................ Date: ...............................

Note :

Starting from 01st June 2010, all credit card payments require three working days to clear with our bank before air tickets will be issued.

Signed form must be accompanied by ( mandatory ):
1. Passport copy and photocopy your credit card both front & back sides.
2. Please send the copies of your credit card both sides together with this signed form to our above address
or fax documents to : +662 2669580 or +662 2669581 ( Local ) : 02 2669580 or 02 2669581