I hereby authorized IMPERIAL IMPALA HOTEL, BANGKOK   to charge the

amount of USD $                                                                                        .

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 : _____________________

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

Please kindly print this form, fill-in your details and fax it back to our Bangkok Office at
(66 2) 541-9574 AttN. Miss Varin E-mail :rsvn@asianetonline.com
Remarks : The charge will be exercised only in case of No-Show or cancellation less then 48 hours
before arrival. If guests come to stay in the hotel, this charge will be cancelled and guests have to pay in
full amount at the hotel.