Phuket Gazette Credit Card Payment Form

Please print out and fill out this form completely,
faxing it back to us at (66-76) 615240.


I hereby authorize The Phuket Gazette Co Ltd to charge
____________  Thai Baht to my Visa or MasterCard for
__________________________________

Cardholder’s Name:
(as on card)		 _______________________________
Card Number: _______________________________ Exp Date: _________
   
Security Code*:
 (Last 3 digits only) 		______________
 
Issuing Bank: _______________________________   Country: __________________________
Cardholder’s
Address:
(as on card account)
_______________________________

_______________________________

_______________________________

_______________________________
E-Mail Address: _______________________________
Tel: ______________
Signature:
(as on card)		 _______________________________
 Date: _________

* This is the number on the back of the card, just above the signature.

Details for your receipt from The Phuket Gazette Co Ltd
Your Name:
 _______________________________

Company Name:
(optional) 		_______________________________
   
Address: _______________________________

_______________________________
City: _______________________________

State/Province: _______________________________

Country: _______________________________
 
Zip: __________