Please complete the form and Fax it to 91-11-51546820

I , national of and owner of the

(Write Name as shown on Credit Card)
Credit Card, Hereby Authorize M/s CULTURE HOLIDAYS(INDIA) PVT. LTD.,

To charge my Credit Card                      Visa      MasterCard    

Credit C. No. Valid Thru CVC No

                                                                                         ( a 3 digit number written on the back of card)

If Credit Card Issued by Bank? Name City 
 

Amount Amount
                (Write Clearly in words with Currency in INR)                                  (In figures INR)

for  travel services being provided to us.

My Credit Card billing Address with my bank 

City   Zip/Pin Code   State   Country

Tel No. as with CC bank  (H)   /(O) / (Mob)      

               (With Country code & City code)

Birth date of CC Holder (mm/dd/yy): Place of Birth

Email Address   Fax : ­

My Passport No. Nationality Mothers maiden name

 I attach herewith scanned or photocopy of my Credit Card (Front & Back) along with  

 Passport for signature authentication.

DECLARATION:

By signing below, I acknowledge charges described above and the payment will be made to you by Credit Card undisputed, when billed to me by Credit Card Company as a Signature on File Transaction.

X_________________________ Print Name as on the Card ________________________

    (Signature of Cardholder)

Place: _______________________                              Date : ________________________

NOTE :

-   The information is required by the Credit Card Co. being SOF, to avoid any misuse.

-   Please complete above form and Fax to 91-11-51546820 or Email as a scanned file.

-   False information will be sufficient cause for denial of services.

-   The INR equivalent will be charged by CC bank .