Credit Card Form
This is to authorise : eINTERNETWORK CO., LTD., THAILAND
To Debit Baht :
Against Credit Card Type :
(VISA, MASTER, JCB, AMEX CARD only)
Batch Code :
(4 digit no. - AMEX only)
Credit Card Number :
The last three digit number
appearing on the signature panal :
Cardholder's Name :
Expiry Date :
Passport Number or
Indentity Card Number :
For the payment of :
Booking under the name of :
Period of Booking :
Cardholder's Signature :
 .
Date :
Remarks : Kindly please print this form, fill-in your Credit Card details and fax it to our Bangkok Office at (66-2) 325-0926 attn. Ms. Polly
Koh-Chang.com
Leisure Island Resorts
Bangkok Office : Tel. (66) 2751 5267 to 8 (66) 2325 0927 to 8 (66) 2751 5224 Fax. (66) 2325 0926
Hotline : (66) 8 1850 3416, (66) 8 3989 6450, (66) 8 3989 6455
E-Mail : reservation@koh-chang.com Attn : Ms. Polly
Copyright by eINTERNETWORK COMPANY LIMITED
All rights reserved
TAT TRAVEL LICENSE No. 11/02161