Authorisation for credit card deduction

Please complete this form, print it out and fax it to
(+49)/ 72 48 / 93 20 95

Name and address
of payee:
Bal-Tours GmbH
Im Gewerbegebiet 22
D-76359 Marxzell

   
Name and address of card holder:
   
surname:
first name:
street, No.:
postal code:
place:
   
I hereby declare myself to be agreeable with the deduction of my
credit card.
   
bookingnumber/invoicenumber
   
Deduct from my credit card (American Express, VISA, Master/Eurocard)
 
credit card-firm (AX, VI, MC)
credit card-number
validity of credit card (e.g. 09/2011)
CVV-number (on the back of your card - last three digits)
sum in EUR
 


credit card applies to
future payments
 
date:
   
Signature of credit card holder:
please sign on the hardcopy!