Credit Card Payment Authorization - Fax Form

Please print this form, fill it out completely, and fax it to any of the following ULTIMA T&T fax numbers: 

+66-2-2546079, +66-2-6538152

I hereby authorize ULTIMA T&T Co., Ltd to charge  _____________ US$

(___________________________________________________US$only***) 

to my  *Visa* *MasterCard* *JSB* *AmEx*  (circle one) credit card.
Cardholders Name:
(as it appears on card)		  
Guest's Name:
(if different from above) 		 
Card Number (include last tree digit number located on the back of your card, signature area)  
Expiration Date:  
Cardholder's Address:  
Passport Number:  
Nationality (as in Passport):  
E-Mail Address:  
Hotel's / Dates:  
Signature:
(as it appears on card)