CREDIT CARD PAYMENT AUTHORIZATION FORM

Cardmember's Name ( as on card ) _________________________________________________________________________

Credit card billing address ________________________________________________________________________________

_______________________________________________________________________________________________________

Tel. ( ____ ) __________________ Fax : ( ____ ) __________________ E - mail ______________________________________

Date of Birth : ___________________________ Passport No : ______________________ Nationality : ___________________

I hereby authorize A.T.N. INTERTRADE to charge the amount of _____________________________________ Thai Baht

Amount in words : ________________________________________________________________________________________

on my :

Visa Card

Master Card

Card Number : ___________________________________________________________________________________________

Expiry Date ________________ Issued by ( name of bank ) _______________________________ Country ________________

The last 3 digits number on signature panel is _____________ ( for VISA & Master Card )

To pay for ( details of purchase or payment ) __________________________________________________________________

________________________________________________________________________________________________________

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

Signature of Cardmember ___________________________________________________ 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 +662 266 9581 ( Local ) : 02 2669580 or 02 2669581

For Official use only
Amount in Thai Baht _______________________ Approval Code : _________________________ Date ___________________
Merchant Number : 200603256