Dear applicant, please write in BLOCK letters, Type it, and fax it back to GARDEN HOTEL.
Date: _______________________
IDENTIFICATION
|
Full Name: Date of Birth: |
|
Company Name: |
|
Type of Business |
|
Address: |
|
|
|
P.O.Box: Tel: Fax: |
DESCRIPTION OF THE SERVICE
|
1: HOTEL RESERVATION Amount (U.S $) |
|
2: Amount (U.S $) |
|
3: Amount (U.S $) |
METHOD OF PAYMENT
|
* MASTER CARD |
|
Card Number: I I I I I I I I I I I I I I I I I CVC2 ( ) |
|
Date of Issue: Expiry Date: |
|
Issued By: Bank Name: |
|
Country: |
Merchant Name: --------------------------------------Merchant Number: -----------------
I the undersigned, hereby certify that all the information given in this application is true and Correct to the best of my knowledge
Date ------------------------------ Signature: -------------------------
I the undersigned --------------------------------------- Authorize -------------------------
To bill my invoice to my MASTERCARD NO. I I I I I I I I I I I I I I I I I
This request is accepted by me and cant be revoked.
----------------------- -----------------------------------------------
Date Signature
FOR FRANSABANK use only.
Amount Reserved_________________ Authorization No.____________Date:__________
___________________________________________________________________________