SAVE this form .. then return to previous page

CREDIT CARD CHARGE AUTHORIZATION

To

Andetur Brazilian Travel Club., Montegut, LA (Natal, RN, Brazil)

PLACE CREDIT CARD INFORMATION IN THE SPACE PROVIDED, THIS IS FOR YOUR PROTECTION.   DO NOT SEND TO US UNLESS REQUESTED.

BY FAX (INTERNATIONAL) , SEND TO:

FAX MAILBOX: 001 (603) 250-5298 or (800) 878-7370

OR BY MAIL TO:

P.O. BOX 52, MONTEGUT, LOUISIANA 70377

TO EXPEDITE BY PHONE, CALL:

Donald R. Reid : 001 (985) 594-0147

ALL PHONE ORDERS STILL MUST EITHER FAX OR MAIL THIS AGREEMENT!

____ VISA ____ Master Card ____ Other

 

Passenger Names _______________________________________________________________________

 

 

 

Description of charge ___________________________________________________________________

Reservation # _______________________________ Date:_______________________________

Name as it appears on Card ______________________________________________________________

CC# __________________________________________ Exp. _______________________________

 

Home address of Card Holder:

 

 

 

Home phone: ____________________________________ E-mail ______________________________

The issuer of the card identified on this item is authorized to pay the amount as shown as TOTAL upon proper presentation.  I promise to pay TOTAL (together with any other charges due thereon) subject to and in accordance with the agreement governing the use of such card.

Signature of Card Holder: ________________________________ Date: