Rc Logo ORIGINAL RICH COLLECTION  

 

LETTER OF AUTHORIZATION

  • Please print and complete this form, and fax it to us.
  • Do not send by email for security sake.
  • Please have your credit card ready to fill out the form.
  • Name and address must be the same as given to the credit card company

Today's Date:
Name on Card:
Email Address:
Address Line 1:
Address Line 2:
Country:
Passport Number:
Date of Birth:
Order Number:

(Given to you when confirming your order by fax or email.)

I, hereby authorize Original
Rich Collection to debit the sum of		 .00 Baht from my credit card below
Credit Card


Card Number:
Expiry Month:
Expiry Year:
For American Express,
please mention the four digit
number appearing on the center
right hand corner.
   
For Visa Card please mention
the three digit number
appearing on the back side
of the card.
SIGNATURE : ____________________________________________________________