<< BACK TO HOME PAGE -   Via S. Pellico 6
33043 Cividale del Friuli (UD) - ITALY
Tel: +39.0432.732.882 - +39.339.7245055
Fax: +39.0432.734.386
Web: www.discoverfriuli.com
E-mail: info@discoverfriuli.com
  V.A.T. IT 02130350305
Regional authorization 238TUR/2000
Insurance company : Mondial Assistance
Insurance policy no. 164859
 
CREDIT CARD AUTHORIZATION FORM
This form must be completed and faxed to us (fax: +39.0432.734386), together with:
- a copy of back and front of credit card
- a copy of cardholder's ID (containing photograph and signature)
In lieu of my credit card imprint, I _____________________________________ hereby authorize
Euroconnections S.r.l., owner of Discover Friuli trademark and Mitteltur travel agency, to charge my
credit card for payment of the travel services listed below.
CARDHOLDER DETAILS:
Name: Daytime telephone no.:
Billing address: Evening telephone no.:
  Fax no. :
E-mail address:
PAYMENT AMOUNT:
Please itemize the travel services that you would like us to charge to your credit card.
Item  Item cost No. requested Total
 
 
 
Amount that we will charge to your card (please tick):
Deposit
Final payment
CREDIT CARD DETAILS:
Card type:    VISA
 MasterCard
Cardholder's name:
(as it appears on the credit card)
Card number:
Expiry date: Security code:
(3 numbers on signature strip)
Name of issuing bank:
I have read and agreed to all of the terms and conditions of booking with Discover Friuli.
Date Cardholder's signature
................................................ ................................................
< click here to PRINT the form >
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