DBA Travel House USA
1282 Taus Circle
Yorkville, IL 60560
Ph: 1-866-424-0602
www.travelhousenepal.com
CREDIT CARD AUTHORIZATION FORM
This Form Must Be Fully Completed For Issuance/Reissuance/ Refund
Passenger (s) Name : ______
Phone Number : ______
Airline Reservation : ______
Ticket Number : ______
Date of Departure : ______
CREDIT CARD HOLDER INFORMATION
Cardholder’s Name As It Appears On The Credit Card:
Cardholder’s Complete Billing Address:
______
______
______
______
Cardholder’s Phone Number:
(Res) ______
(Cell) ______
Cardholder’s Relation With The Passenger (s): ______
CREDIT CARD # : ______
DATE OF EXPIRY: ______CCV Code:______
TOTAL AMOUNT:$ ______
I (Card Holder) ______Authorize Travel House Nepal To Charge My Credit Card, For The Above Mention Amount For Issuance/Reissuance/Refund Of The Ticket.
Card Holder Signature: ______Date: ______
Please fax the complete form and copies of both sides of your credit card and driver license. We will be able to process for issuance or reissuance or refund your ticket after receiving the complete copy of this form. If you have any queries, please feel free to call us.
Fax No:1-866- 295-6822