Card Members Name |
: |
___________________________________________________________ |
Card Account Number |
: |
___________________________________________________________ |
Card Type : Visa/Master/Amex/other |
: |
___________________________________________________________ |
Validity of the card |
: |
___________________________________________________________ |
E-mail ID |
: |
___________________________________________________________ |
Service Description |
: |
___________________________________________________________ |
|
|
___________________________________________________________ |
3 Digit Verification Number |
: |
__________________________________(Visa / Master) __________ |
4 Digit Verification Number
given on the front side
|
: |
__________________________________(Amex)_________________ |
Billing Address |
: |
__________________________________________________________ |
City |
: |
___________________________________________________________ |
State |
: |
__________________________________________________________ |
Country |
: |
__________________________________________________________ |
Card Members Contact Telephone Number |
: |
__________________________________________________________ |
I the undersigned, hereby authorise Bangalore-hotels-reservation.com, to charge my Credit Card with the above
said details for the amount of
Rs._____________________________________________________________________________
|
Date : |
Signature: |
(Matching the card) |