CREDIT CARD FORM
Your Credit Card is Safe with eNetherlandsHotel.com

E-Business Alliance Co., Ltd. (eNetherlandsHotel.com)

Please debit (Amount) ................................................................... EUR

Against Credit Card : ..............................................................
[ VISA, MASTER, AMEX, or JCB ]

Credit Card No. .............................................................................

Cardholder Name : .........................................................................

Expiry date : ................................................................................

E-mail : .......................................................................................

Please advise the last three-digit number or four digit number (for AMEX)
appearing on signature panel (if any) : .................................. (See example)

For payment of : ..........................................................................

Hotel name/City : ............................................................................

Guest name : ............................................................................

E-mail address : ............................................................................

Signature of Cardholder : ...............................................................

Date : ........................................................................................

*********************** IMPORTANT **********************

Please print this form, fill-in your details and fax it back to our Bangkok Office at (662) 643-1193, (662) 246-2259 Att. Jane E-mail : info@eNetherlandsHotel.com