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I, ________________________________, authorize Faremax, Inc.
and Russia House Travel, Inc. issuing the tickets reserved on the
Balkan Info Home Web site to charge my Credit Card in the amount
of $____________ (including 4% Credit Card surcharge) for the
[purchase][cancellation][change] of my International Flight
reservation.
| PNR(Reference#): |
______________________ |
| Card Type (check one): |
[ ]AMEX [
]Discover [ ]Visa [
]Mastercard |
| Card Holder Name: |
______________________________________________ |
| Credit Card Number: |
______________________________________________ |
| Expiration Date: |
______________________________________________ |
| Three-digit Security Code: |
______________________________________________ |
| Billing Address: |
______________________________________________ |
| Billing Phone: |
______________________________________________ |
___________________________________________ __________________
Card Holder
Signature Date |
Please print and fill out this form. Please, mail it to the
address above. Alternatively, scan it and send it as an E-mail attachment to
webmaster@b-info.com.
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