I hereby authorized IMPERAL TARA HOTEL , MAE HONG SON   to charge the

amount of US$                                                                              

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 : _____________________

*********************** 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