Patong Bootery Credit Card by Fax form

For Print Credit Card Authorization Form

1.Clict on GO button.

2.Complete answer all Questions and choices below.

3.Click menu File on the menu bar of your browser,

3.1Choose Print preview,

3.2Choose print page 2 of 3.

Finish.

Patong Bootery Credit Card Authorization Form
We understand the need for security and the necessary concern for transmitting
credit card information over the Internet. This FORM is an alternative to assist you
easily and safely. This FORM can not be sent over the Internet.

Please follow these few easy steps.
1. Complete answer all questions and choices below.
2. Print the FORM
3. Sign the FORM and fax directly to Patong Bootery. Keep this signed original copy.

Choose card type

NUMBER on Credit Card

Last 3 digits of Authentication Number on the back of the credit card
NAME as printed on Credit Card

Valid To Date

Please provide us with the Billing Address used for this Credit Card
Street Address
City, State / Province
Country & Postal Code

Telephone of Card Holder
Country Code
City Code Number

Email Address
Description of the payment / purchase / credit transaction

To: Thai Military Bank Public Company, Patong Branch
(85/4 Taweewong Rd., Patong Beach, Kathu, Phuket 83150)
Account Name: Somphong Khunphakdee
Account Number: 444-1-00137-9
This is to give my permission for Patong Bootery,100/16-17 Taweewong Road,Patong Beach,
Phuket 83150,Thailand to use this signed fax as a substitute in place of my actual credit
card for the purpose of making a payment transaction that will be applied to mycredit card.
The TOTAL Credit Card withdrawal Amount is NOT TO EXCEED .00 Baht
Same Amount written in words .00 Baht

PLEASE PRINT THIS FORM NOW Sign this FORM just as you sign your credit card, then fax this FORM directly to
Patong Bootery,Tel & Fax: (66) 076.341.342. Please keep your printed copy for your records.

SIGNATURE (as used on credit card) ________________________________

DATE _________/___________/_____