Credit Card Authorization Fax Form:
Please print this from, fill it out completely and elaborately, and send it
By fax to Thailand 662 965 7516 attention to Mr.Chatchai Homruenrome
I _________________________________________ (Your name) authorize a charge
Of _______________________________________________ (Fill in amount)
Credit Card Type: ______________________________________________________
To my
Master Card
Visa
Reservation Number:
Cardholder's Name:
(As it appears on card)
Guest's Name:
(If different from above)
Departure/Check In Date:
Return/Check Out Date:
Bank Issuer's Name:
City & Country Issued:
E-Mail Address / Telephone:
Credit Card Number:
Expiration Date:
(MM/YY)
Security verification code:
(3-4 digits, see location on the right)
Signature of Card Holder:
* I understand that the services, for which BAAN KOH MAK. Will charge my credit card for, may not be
refundable and there may be penalties for changes. By Signing on this document, I also acknowledge that I
understand, abide by, and agree to all term of
Fraud Prevention Information
The card Identification Number (Card ID) is required for Visa and MasterCard. The
Card ID is an added security feature to help protect you against online fraud.
Visa Card
Last 3 digits on back of card
Master Card
Last 3 digits on back of card
All requests for cancellation must be sent directly to us by e-mail at:[email protected] or fax to +66(2) 965 7516