I hereby authorized CHAWENG BURI RESORT, KOH-SAMUI   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 :                    

Expiry date :                                     Card company :                                        

Country:                                               

SIGNATURE : _______________________________ Date : _____________________

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