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International
Credit Card - Charge Authorization Form
Natival Tours S.A.
San José, Costa Rica
Phone: +(506) 289-4292
Fax Numbers: +(506) 289-8591 or +(506) 215-3451
Electronic mail address: info@costaricashuttle.com
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NOTICE!
Please fill out this form, print it and send it by fax
or email a scanned copy in order
to complete your reservation.
IS MANDATORY TO ATTACH TO THIS FORM A PHOTOCOPY OR
SCANNED IMAGE
OF YOUR CREDIT CARD BOTH SIDES AND SEND IT BY FAX (Above
number) OR EMAIL ATTACHMENT (Email address above).
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Date (day/month/year): [____/____/______]
I
[___________________________________________________]
hereby authorize
(As it appears on the
credit card)
Natival Tours S.A. to
charge my Credit card type
1. VISA mark with an X [ ]
/ 2. MASTER CARD mark with an X
[ ] / 3. AMEX mark with an
X [ ]
Credit Card number
[___________________________________________________],
Expiration Date
(month/year) [____/______], Issue date (month/year)
[____/______]
in the amount of US$
__________._____ .Bank Code (3 Digits Card ID)
[______].
Concept of charges: Transportation in Costa Rica,
Central America. Final method of payment
1. Same credit card above mark with an X [
]
2. Cash or travelers cheques to the driver mark with an
X [ ]
Credit Card holder's signature Confirmation
number:[____________________]
I have read and accept
the terms and conditions of the reservation and agree to pay
the amount here authorized, even though I have not signed
the original voucher in case of I don't show up the day of
the service or if I cancel the service within the term 7
days prior departure or if I expressly chose this same
credit card information as my final method of payment.
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