CREDIT CARD PAYMENT FORM

Pay to the order of:

   CHIANG MAI ADVENTURE TOUR & TRAVEL
   131-133 Rachadamnern Rd.
   T.Prasing, A.Muang
   Chiang Mai 50200 Thailand

   Fax No. (66-53) 27 7810

For tour service arrangement and period:

   Starting date:__________________________

   [ ] Tour Service  [ ] Accommodation

Type of credit card:

   [ ] VISA [ ] Master Card

Card Member's Name:___________________________

Card Number:__________________________________

CVV2 (3 digits):_______________________________
(CVV2 is a 3-digit value printed on the back of your credit card)

Expiration date: _____________________________

Amount authorized to charge:__________________

Signature as on card: ________________________

Date: ______________________

Thai commercial banks require that the cardholder 
submit a photocopy of his/her passport before his 
credit card account can be charged. So, please 
send us a copy of your passport (both signature 
and photograph pages) together with this form. 

Thank you very much.