FAX NUMBER : 66-76-341312 FROM : ________________________ TO : Phuket Palace Co., Ltd Page : ____ of _____ Enclosures : ________________________ Fax Credit Card Authorization Form Phuket Palace To book your room please complete the below form and mail it back to our address below. I, (Name)___________________________authorize Phuket Palace Co., Ltd. to charge __________US Dollars to my _____________ Card. Card Holder Name : ________________________ Card Number : ________________________ Passport Number : ________________________ Signature as on your Card : ________________________ Expiry Date of your Card : ________________________ ____________________
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