credit card authorisation form

_______________________________________________
Full name of credut card holder
PLEASE FILL IN WITH CAPITAL LETTERS
_______________________________________________
Billing address given to card issuing bank
_______________________________________________
Phone number to cardholder
CREDIT CARD
AUTHORISATION FORM
Having in mind regulations of article 10. Act on electronic payment methods (PL: Ustawy o elektronicznych
instrumentach płatniczych) dated 12 Sep 2002 (Dz. U. z 2002 r. Nr 169, poz. 1385 oraz 2004 r. Nr 91, poz. 870, Nr 96,
poz. 959.) payment procesor may ask for additional identification of cardholder prior to trans action when credit car dis
not prezent. Thus,
I, whose signature is below _______________________________________________,
The holder of credit card:
VISA
American Express
MasterCard
DinersClub
exp date
(month)
(year)
CVV2/CVC2 code
(3 last digits from signature stripe on reverse side of the VISA/MasterCard card – 4 digits in case of AMEX card)
hereby authorise Sonata Travel Ltd. in Warsaw, operator of www.Lataj.pl, to charge my credit card for tickets on
route: _______________________________________________
Booking reference no: _______________________________________________ for passengers:
1) _________________________________
3) _________________________________
2) _________________________________
4) _________________________________
Cardholder’s signature:
_________________________________________
PLEASE PRINT, FILL IN AND FAX
+48 (22) 201 11 63
OR E-MAIL TO
[email protected] ALONG WITH COPY OF MAIN SIDE OF CREDIT CARD
DEAR CUSTOMER, IF YOU DISAGREE WITH OUR BILLING POLICY AND YOU REFUSE TO SEND ADDITIONAL CREDIT CARD DETAILS
ALONG TO IDENTIFY CARDHOLDER, PLEASE CONTACT OUR CALL CENTER: 0-801 401 801 …. +48 22 201 11 60 IN ORDER TO
CHANGE PAYMENT METHOD TO BANK/WIRE TRANSFER. IF YOU CHOOSE SO, PLEASE TRANSFER TO BANK ACCOUNT:
SONATA TRAVEL SP. Z O.O., WARSZAWA, PIĘKNA 16
BRE BANK: PL 87 1140 1010 0000 3675 2500 1001 SWIFT CODE: BREX PL PW