Jungle Lodge Credit Card Authorization Form 

We understand the need for security and the necessary concern for transmitting credit card information over the Internet.  This FORM is an alternative to assist you easily and safely. 
This FORM CAN NOT be sent over the Internet. 

Please follow these few easy steps.
1. Complete answer all questions and choices below.
2. Print the FORM
3. Sign the FORM, scan and email directly to Jungle Lodge.  Keep this signed original copy.
 
Choose card type
NUMBER on Credit Card 
-
-
-
Last 3 digits of Authentication Number on the back of the credit card 
NAME as printed on Credit Card 
Valid To Date

Please provide us with the Billing Address used for this Credit Card
Street Address 
City, State / Province 
Country & Postal Code 
Telephone of Card Holder
Country Code 
City Code 
Number 
Email Address 
Description of the payment / credit transaction

To: Krung Thai Bank, 63 Klang Keow Road, Takua Pa, Phang Nga 82110 Thailand
Account Name: Francis Rogers
Account Number: 810-1-18958-0
This is to give my permission for Jungle Lodge, 27/1 Moo 3 Ban Lam Ru Road, Kapong
Kapong, Phang Nga, 82170 Thailand to use this signed fax as a substitute in place of my actual credit card for the purpose of making a payment transaction that will be applied to my credit card.

The TOTAL Credit Card withdrawal Amount is NOT TO EXCEED .00 Baht
Same Amount written in words .00 Baht

PLEASE PRINT THIS FORM NOW
Sign this FORM just as you sign your credit card, then scan and email this FORM directly to
Jungle Lodge, Email: artsriverviewlodge@yahoo.co.uk . Please keep your printed copy for your records.

SIGNATURE(as used on credit card) ________________________________ 

DATE _________/___________/_____ 

THANK YOU   Please  use your back arrow to return to the Jungle Lodge main page.