Cardholder's name___________________________________________________

Billing Address : _____________________________________________________ __________________________________________________________________

Country : ________________________ Zip Code : ________________________

I hereby authorize Phuket Experience Tour Co., Ltd. to charge:

Amount in US$ ___________________ or in Thai baht ______________________

( ) Visa Card ( ) Master Card ( ) American Express ( )

Other Credit Card Type of Card ________________________________________

Card Number :______________________________________________________

Cardholder's name ( as appears on credit card )_____________________________

_________________________________________________________________

Expiry date ( dd/mm/yy ) _______________________________________________

Comments :_________________________________________________________

___________________________________________________________________

Signature of Cardholder: ___________________

Date : ___________________