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amount of USD                                                                                         .

from __                                ___ to:                                             

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Guest's Name :                                                                             (if different from above)

Card Number :                                                                                     

Expiry date :                                     Card company :                                        

Country:                                               

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