CREDIT CARD PAYMENT FORM - Grand Mercure Fortune
To guarantee your booking, please printout this form, complete all the information and
fax to Bangkok office : Fax (662) 5419574
===> Full payment will be charged trhough your credit card 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                                                                                  

to my credit card for my accommodations from __________________ to:                                       

Cardholder's Name :                                                                      (as it appears on card)

Guest's Name :                                                                             (if different from above)

Credit card no.                                                                                   Expiry date :                                    

Please write down the last 3 digits show on the back of the card ______________________

AMEX CARD : Please inform billing address_____________________________________________

Credit 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