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Creditcard Authorisation form
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This form is to be printed and then faxed to number in South Africa.
Please click the printer icon before printing
 
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Credit Card Authorization |
| Customers Full Name: |
_______________________________ |
| Customers Address: |
_______________________________ |
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_______________________________ |
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_______________________________ |
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_______________________________ |
| Date of Birth: |
__ __ / __ __ / __ __ __ __ |
| Passport No: |
________________________ |
| SA Resident I.D. No. : |
____________________________ |
| Card Type:(Visa / MasterCard) |
__________________ |
| Bank Name |
__________________ |
| Card No: |
___________________________________ |
| Expiry Date: |
___ ___ (mmyy) |
| CVC No. __ __ __ |
(Last 3 digits on back of card if applicable.) |
| Amount as per invoice no . |
Inv.____________ ZAR ________ |
| Date of Transaction: |
__ / __ __ / __ __ __ __
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I ___________________________ the undersigned give approval to African Timeout to debit my credit card (details above) with the amount of R ________________ to secure payment for my tour.
_______________ Signature
Date:_____________
Please fax this authorization to South Africa
+27 86 511 7679
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