Please print this form on your local printer & fax the filled in form to +91-821-2344143 along with the Photo copies of both sides of your Visa / Master card. Foreign National / Non Resident Indians are required to also fax us a copy of their passport. |
| Date :- From :- ( Name & Address ) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... To, M/s Safe Wheels Tours & Travels CH-16, 4th Main, 5th Cross
Saraswathipuram, Mysore-570009. Karnataka, India. Ph: Off: (0821) 2547543/2342543 Fax : 0821-2344143.
I authorize M/s Safe Wheels Tours & Travels to debit my Credit card No............................ for amount of .......... Payable in respect of the services being requested .............................. .............................. My personal details are as follows :- Date of expiry of Credit card ( Month and Year ):- .............................. CVV :- .............................. Mother’s Maiden Name :-.............................. Residence telephone No :- .............................. Nationality :- .............................. Date of Birth :- .............................. Sd/- ( Signature as on the credit card ) ( Name of the card holder ) .............................. Please Note :- *Xerox copy of front & back of the credit card. *Xerox copy of passport ( If transaction amount exceed Rs.10000/- on International cards ) *Signature should be the same on the authorization letter & credit card photo copy. Print This Page |