(The required amount to be paid is full payment of the first night of total booking)

I hereby authorized  IMPERIAL SAMUI HOTEL   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 :                                                                                     

Expiry date :                                     Card company :                                        

Country:                                               

SIGNATURE : _______________________________ Date : _____________________

Please kindly print this form, fill-in your details and fax it back to our Bangkok Office at
(66 2) 541-9874 Att. Miss.Varin E-mail : rsvn@asianetonline.com