Credit Card Information Fax Form

In order to continue with your booking you must fill out this form and fax it to Agoda along with either:

a A photocopy of the front/back of credit card and a photocopy of a valid Photo ID.
OR
b Your most recent monthly credit card statement / bill from your card issuer or bank
(not more than 2 months old).
old)

Please print this form, fill it out completely, and fax it to any of the following Agoda Travel Network SECURE
fax numbers. Please be careful to enter the fax number correctly to ensure your data is safely received.

USA: 1-800-382-2451 UK: +44-20-8711-2230

Thailand: +66-2-613-1764 France: +33-1-57-31-76-66
Japan: +81-3-4496-5496 Germany: +49-32-211-0899-0460
Singapore: +65-6491-5656
65 6491 5656 Spain: +34-91-181-41-01
34 91 181 41 01
Hong Kong: +852-3017-6768 Italy: +39-066-051-3870
Malaysia: +60-32-178-4444 Australia: +61-2-8088-8088

Booking amount ___________________________________________

We will confirm your documents have been received within 24 hours.

Please contact us if you have not received confirmation after that time.

Cardholder's Name:
(as it appears on card)

Guest's Name:
(if different from above)

Card Number:

S
Security
it Code:
C d
(4 -digit number on the right of your Amex card OR the last 3-digit number appearing on the signature panel on the reverse side of
your MasterCard/Visa/JCB)

Expiration Date:

Name of Issuing Bank:

Telephone No. of Issuing Bank:

Credit Card Billing Address:

Passport Number:

Telephone Number:

E-Mail Address:

Hotel Name:

Check in: Check out:

Booking ID:

Other Information:

Signature:
g
I the cardholder hereby authorize this charge to my credit card for the hotel booking detailed
above made under the name of the guest indicated above. (Please ensure that your signature
matches the signature on your Credit card/photo ID.)

Copyright @ 1997 - 2009 Agoda Company Pte Ltd