ULTIMA TRAVEL Credit Card Payment Fax Form


	ULTIMA TRAVEL 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 (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)