| CREDIT CARD AUTHORIZATION FORM | ||||
| Explanation | This document will enable us charging your credit card for the services mentioned below | |||
| Name of the person | __________________________________________ | |||
| Number of package | P1 P2 P3 P4 P5 (Please mark the proper one) | |||
| Number of person | ____ | |||
| Name of the credit card holder | __________________________________________ | |||
| Total fee will be charged | _________ US$ / _________ EUR / _________ GBP (Please pick suitable one) | |||
| Service will be handled by | DEREN KORAY TOURISM - PsoriasisFishCure.com | |||
| Additional info | __________________________________________ | |||
| Card Type | [ ] VISA [ ] MASTERCARD [ ] AMERICAN EXPRESS | |||
| Card Number |
__ __ __ __ |
__ __ __ __ |
__ __ __ __ |
__ __ __ __ |
| Security code of the card | __ __ __ The last three number of the backside (Please write clearly in both sections) | |||
| Expiry date | Month ________ Year ________ | |||
| AUTHORIZATION | ||||
| Explanation | I authorize DEREN KORAY TOURISM to charge my credit card by accepting the terms and conditions for the purpose of providing the services above | |||
| Signature | ___________________________________ | |||
| Current Date | ______/_______/______ | |||
| IMPORTANT ! | Please fax this form to +90 232 4410437. Thank you | |||