Contact Information
Name:


(Title)


(First Name)


(Middle Name)


(Last Name)
Address 1:
Address 2:
City: Zip Code:
Country:
Phone: Fax:
E-mail:
 
Identity Information
Identity:
Place of Issue:
Date of Issue:
 
Credit Card Information
Holder of: Expiry Date:
Name as on Card:
Card No: Security Code* :
*Security Code is applicable on American Express credit card only. It is the 4 digit Code above your Credit Card No.
For Amount of : (in figures)
(in words)
Select Service:
I understand that the Records of Charges - in respect of goods/services received/availed - submitted by you to the Credit Card Company or the airlines will neither bear my signature nor the imprint of my above Credit Card, and I therefore, undertake to unconditionally honour and pay without demur and contestation, the said charges, as and when I am billed for the same by Credit Card/ Airline.

Thanking you,

Yours sincerely,


______________________________
(Signature as it appears on the Credit Card)
Name as on the Card:
Date:
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NOTE : Please make your selections and take the printout of this form & Fax along with a photocopy of both sides of the credit card, Driving License or your passport to fax no. 91-11-6852423 to enable us to collect payment from Credit Card Company.
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