Letter of Authorization

Today's Date:
  • Please print and complete this form, and fax it to us. Do not send by email for security sake.
  • Please have your credit card ready to fill out the form.
  • Name and address must be the same as given to the credit card company
  • Click here to print this form.
Name on Card:
Email Address:
 (please provide your email address)
Address Line 1:
Address Line 2:
Country:
Passport Number:
Date of Birth:
Order Number:
(Given to you when confirming your order by fax or email.)

I, hereby authorize Grace Tailor to debit the sum of
US$ from my credit card below
Credit Card AMERICAN EXPRESS
 MASTER CARD
 VISA
Card Number:
Valid Until: Month:  Year:
For American Express,
please mention the four digit number appearing on the center right hand corner.
For Visa Card,
please mention the three digit number appearing on the back side of the card.
Signature as on Card ____________________________________________
 

PLEASE FAX OR MAIL THIS FORM TO:
Grace Tailor
363/27 Soi Saensamran
South Pattaya, Cholburi 20260
Thailand
Tel: +66 3 8710736
Mobile: +66 1 9838440
Fax: +66 3 8710736