Contacts info TO: Alliance Travel Company Fax: 7 812 579 9396 Tel : 7 812 579 9933 E-mail: info@visatorus.com FROM: Phone: Fax: Company: Credit cardholders authtorization I lieu of my credit card imprint I (name of credit card holder shown on credit card) hereby authorize "Alliance Travel Company" to charge my credit card. AMEX VISA MASTERCARD DINERS CLUB INTERN. JCB # Valid till : / MM/YY In the amount of. Batch code (4 figures just above the main line of figures) : / / / (for AMEX cards only) This charge is related to travel services for myself and/or (full name of each passenger if other than cardholder) : For the following services: My billing address: Phone: Fax: E-mail: By signing below, I acknowledge charges described herein. Payment in full to be made when billed or in extended in accordance with standard policy of card issuer. In case of bank canceling authorization, "Alliance Travel Company" has the right to cancel reserved services. While paying by credit card you pay 3% more as tax. Name: Signature of cardholder: _____________________________ Date: "_____" ________________ 200__ PLEASE FAX US THIS FORM BACK TO 7 812 579 9396 or 7 812 579 9933
