Confidential

    CREDIT CARD AUTHORIZATION FORM

To : Handling Agent in Asia

The SMILE of ASIA ( by Boonruan Mongnan )
11/1 Muu 3 Ban Phra Khluay - T. Chompoo - A. Saraphi
50140 Chiang Mai, THAILAND
Tel : +66 (53) 423513
Fax : +66 (53) 423513
Email : info@smile-of-asia.com
http://www.smile-of-asia.com

From : Ordering Customer

Name :         ..................................................................
Home Address :...............................................................
....................................................................................
....................................................................................
Tel : ................................
Fax : ...............................
Email : .....................................................

This form confirms your request for payment by credit card. Your signature below constitutes your agreement to pay any and all amounts charged by
' The SMILE of ASIA ' touroperator, to your credit card account specified below, and authorizes ' The SMILE of ASIA ' touroperator to obtain credit approval from said credit card company.

I,__________________________________( your name ) HEREBY AUTHORIZE ' THE SMILE OF ASIA ' - TOUROPERATOR TO CHARGE MY CREDIT CARD ACCOUNT SPECIFIED BELOW. I AFFIRM THAT I AM AT LEAST 18 YEARS OLD AND THAT I AM LEGALLY AUTHORIZED TO USE THE CREDIT CARD NUMBER SPECIFIED BELOW. FURTHERMORE, I UNDERSTAND AND AGREE THAT ANY CHARGES MADE TO THE ACCOUNT SPECIFIED BELOW ARE FULLY NON-REFUNDABLE, AND I AGREE TO PAY, PURSUANT TO MY AGREEMENT WITH SAID CREDIT CARD COMPANY, ANY SUCH AMOUNTS CHARGED BY ME BOTH IN THE PAST AND HENCEFORTH. ADDITIONALLY, I AGREE TO HOLD ' THE SMILE OF ASIA ' - TOUROPERATOR COMPLETELY AND FULLY HARMLESS FROM AND AGAINST ANY AND ALL CLAIMS OF ANY TYPE OR NATURE WHATSOEVER RESULTING FROM ANY CHARGES MADE TO SAID CREDIT CARD ACCOUNT. PAYMENT IN FULL WILL BE BILLED TO THE CREDIT CARD SHOWN BELOW.

CREDIT CARD TYPE : ______________________ ( specify VISA - MASTERCARD - AMERICAN EXPRESS - JCB - DINERS CLUB )

CREDIT CARD NUMBER : ____ _-__ __-_ ___-_____ ( format ....-....-....-.... )

EXPIRATION DATE : _________________ ( format MM/YY )

CVV - CONTROL NUMBER : _______ ( CVV is the last 3 digit numbers on the signature strip on back of the credit card )

NAME OF BANK ISSUING CREDIT CARD : ____________________________    CUSTOMER SERVICE TEL : __________________

CARDHOLDER NAME :_________________________________________________

CREDIT CARD BILLING ADDRESS :______________________________________________________

PER MY REQUEST THROUGH THEIR ONLINE CREDIT CARD PROCESSING SYSTEM I HEREBY AUTHORIZE ' THE SMILE OF ASIA ' - TOUROPERATOR TO CHARGE ON THE ABOVE CREDIT CARD ACCOUNT.

____________________________              ______________________

Signature ( same as on back of card )        Date ( YYYY-MM-DD )

PLEASE ATTACH COPY OF YOUR ID CARD ( PHOTO PAGE ONLY ) AND YOUR CREDIT CARD ( BOTH FRONT & BACK SIDE ) :

FRONT CREDIT CARD

BACK CREDIT CARD