Tel. (02) 613-7577-8   FAX (02) 613-9684
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: ________________________________