RICHLY TRAVEL CENTRE
Tel. (02) 613-7577-8 FAX (02) 613-9684
info@richlybangkok.com
TAT License #12/343
Credit Card Payment Form
Please print out this form, fill in the necessary data and fax the sheet to:
Richly Travel Centre Fax: +66-2-613-9684.
Beneficiary:
Richly Travel Centre 447 Longmuang Rd. Pratumwan, Bangkok 10330
Payer's data:
Family Name: ___________________________ Given Name: ___________________
Street & House Number: ________________________________________________
City or Town: ________________________ Country: __________________________
Telephone: __________ Fax: ____________ Email: ___________________________
Nationality: ______________________ Passport No.: _______________________
Passport valid until: __________________________________________________
Charge Request for Train and Bus Booking
Date: ______________ From: __________________________ To:_________________________
Class of Service: (1st, 2nd Fan, 2nd Air-Con) _______________ Number of Tickets: _____________
Payable Amount in US Dollars: (in letters) _______________________ (in figures)______________
Credit Card Information:
Credit Card Company: _______________________________________________
Credit Card Number: ________________________________________________
Credit Card Expire Date: _____________________________________________
I hereby authorize Richly Travel Centre to charge the above amount to my credit card.
Date: _______________________ Signature: ________________________________