Credit Card Authorisation Form c. Attach confirmation of your current membership with a registered health insurer indicating appropriate level of policy that covers insulin pumps.
Credit Card Authorisation Form. For office use only: Booking Name Date of Travel Bank Auth. Code Attention: Debtors Team Telephone: +00 00 000 0000 Vax: +00 (0) 000 000 0000 E-Mail: xxxxxxx@xxxxxxxxx.xxx CREDIT CARD AUTHORISATION FORM: Reservation No. Invoice No. Curr. Invoice Amount Total amount to be deducted - PLEASE NOTE: All amounts will be converted into and deducted in Rand (ZAR) at the Rate of Exchange applicable on date of the transaction. The quoted exchange rate and amount in ZAR is valid for a period of three days from date of quote. Diners Club Master Card Visa Card Card Type: Bank Name: Expiry Date (MM/YY): Card Number: Security No: Last three (3) digits on the back of the card: Name (as printed on card): Billing Address: Contact Telephone Number (Home): Contact Telephone Number (Work): Passport or ID Number: Date of Birth: I, hereby authorise &Beyond to debit my credit card as detailed above Signature: Date: The Above Information is essential to ensure success in processing. Any omissions may result in your card being rejected. Should this be caused by incorrect /insufficient information or insufficient funds, &Beyond reserves the right to release the reservation. Re-instatement will be pending correct/sufficient information and funds, and is subject to availability of room at the time of re-instatement. PLEASE KINDLY CONTACT YOUR BANK TO ADVISE THEM THAT WE WILL BE APPLYING FOR AUTHORISATION TO DEBIT YOUR CREDIT CARD ACCORDING TO THE SPECIFIED AMOUNTS & DATES ABOVE. PLEASE NOTE: IT IS A BANK REQUIREMENT THAT A COPY OF THE FRONT AND BACK OF THE CREDIT CARD IS FAXED THROUGH WITH THIS
