CREDIT CARD FAX FORM - Bacchus Home Resort
Please printout this form, fill it out completely all the information and fax to our reservations
fax line Thailand : at (66 2) 541-9574
Full payment will be charged through your credit card after the reservation is confirmed.
Currently we accept Only Visa, Master Amex or JCB cards.

I hereby authorized  www.asianetonline.com 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/VISA Card - the last 3 digits show on the back of the card :                 

AMEX - 4 digits code :                         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
(66 2) 541-9574 Att. Miss Varin E-mail : rsvn@asianetonline.com