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PEACE BLUE NAIHARN PHUKET RESORT

CreditCardAuthorizationForm

Card type : …………………………………………………………………………………………………

Card Holder name : …………………………………………………………………………………………………

Card Number : …………………………………………………………………………………………………

Expire date : …………………………………………………………………………………………………

CVC / CVV Code : ……………………………………………………………………………………………..…

Payment for : …………………………………………………………………………………………………

Card Holder signature : …………………………………………………………………………………………………

Booking name/group : …………………………………………………………………………………………………

Address : …………………………………………………………………………………………………

Nationalilty : …………………………………………………………………………………………………

Period of staying : …………………………………………………………………………………………………

Room charge : …………………………………………………………………………………………………

Total room charge : …………………………………………………………………………………………………

Card holder signature Peace Blue Naiharn Resort Phuket

( _) Baan Saiyuan, Soi Kokyang Tambon Rawai

Amphoe Muang Phuket, Phuket 83130 Thailand

Tel: +66 (0) 61 539 4695, +66 (0) 61 539 4965

E-mail: peaceblueresortphuket@gmail.com

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