to the Mail Order

AUTORIZAÇÃO DE DÉBITO
Grupo Espirito Santo Viagens
Name:
Adress:
City:
Phone:
 American Express
Date of Birth:
Fax:
 Visa
E-mail:
 Mastercard
 Diners Club
Number:
SecurityCode (back of the card)
Valid:
Issued to:
(name of the holder as it is on the card)
I, ________________________________________________________________________________________________________
authorize TOP ATLÂNTICO to debit on the credit card.
Amount: €______________________________________________
____________________________________.
Concerning: ____________________________________________________________________
Signature:
Date: ____ / ____ / ____
After the form is fulfield please send us by fax or by mail .
Please confirm the adress to send the receipt ( if not the above )