D'MA PAVILION HOTEL-CREDIT CARD FORM
To guarantee your booking, please printout this form, fill it out completely all the information
and fax to our reservations fax line Thailand : at (66 2) 541-9574
In case of no show, one night charge will be charged through your credit card.
Currently we accept Only Visa, Master Amex or JCB cards.

I hereby authorized D'MA PAVILION HOTEL, BANGKOK  to charge the

amount of THAI BAHT                                                                           

from                                               to:                                             

Cardholder's Name :                                                                      (as it appears on card)

Guest's Name :                                                                             (if different from above)

Card Number :                                                                                     

Master Card : write down the last 3 digits show on the back of the card :               

AMEX : please inform Billing address                                                                        

Expiry date :                                     Card company :                                        

Country:                                               

SIGNATURE : _______________________________ Date : _____________________

******************************* IMPORTANT ***************************

Please kindly print this form, fill-in your details and fax it back to our Bangkok Office
at (662) 541-9574 Attn. MISS VARIN E-mail : rsvn@asianetonline.com