Secure Payment Fax Form

Please print this form, ensure that it is filled out completely, clearly and correctly then fax it to us
at: +66(0)53 904033 or 818755 +add you international dialing code. Omit the (0) if you are faxing from outside Thailand

I declare that this card belongs to me and authorize the charge of

US$/BHT __________(amount) to my

MasterCard

Visa

I accept to pay the balance of US$/BHT _______ on (dd/mm/yy) ___/___/___

Payments are credited to our Thai account, translated into the Thai Baht (THB) equivalent. Charges should appear on your credit card statement in your local currency based on the exchange rates and according to your card-issuers policies. *The payee name on your statement will appear as WWW.ELEPHANTNATUREPARK.ORG , THAIFOCUS.COM CHIANGMAI TH or similar.

Cardholders Name:
(exactly as it appears on card)

Travel Plus Number:

Card Number:

Expire Date:

Month:

Year:

Security Code:

The last three-digit number appearing on signature panel of your MasterCard or Visa

Cardholder's Billing Address:
(These details are required!)

Building:
Street:
District:
City:
State/Province:
Zip:
Country:

Passport Number & Nationality:

E-mail Address:

Telephone Number:

Area code:

Number:

Fax number:

Area code:

Number:

Details or Service(s) / Dates:
e.g. Hotel check in date etc)

by signing this form you agree to the charges above and declare that all details are correct and that this credit/charge card belongs to you.

Signature:
(as it appears on card)

Please print this form, fill it out completely, then fax it to Gem Travel, +66(0)53-904033 or 818755

*We charge in dollars and submit our claim, in Thai Baht, to our bank. There is a delay in crediting our account (by the local bank. The overseas card issuer (via visa or MasterCard) translates the amount back into the currency chosen by the card holder. If the US$ is stronger on the day this occurs then the bill will be less than the total US$ amount billed by Thaifocus/Gem Travel. It the Thai currency rises in value (during the time between our submission and the time when the bank submits this to visa) then the amount will be slightly more than the the prices listed on our hotel rates.

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