DEBIT AUTHORIZATION_Balloon - Terra Sol Turismo e Eventos

DEBIT AUTHORIZATION
I authorize Terra Sol Turismo to debit on my credit card account, as it follows:
( ) Visa
( ) Amex
( ) Credicard
( ) Dinners
( )MasterCard
( ) Others
Name: _____________________________________________________________
Conference name: 21st FAI World Hot Air Balloon Championship
CREDIT CARD INFORMATION
Credit Card Holder´s Name: __________________________________________________
Credit Card Number: _______________________________________________________
Expiration Date: ___________________________________________________________
Security Code: ____________________________________________________________
Total Value: ______________________________________________________________
Currency: ( ) USD
( ) EUR
(X) National Currency – REAIS
Travel Agency: TERRA SOL TURISMO E EVENTOS SÃO CARLOS
Phone/Fax: +55 16 3413.0323
2209, Marechal Deodoro Street – São Carlos/SP.
Zip Code: 13.560-200
Passport Number: __________________________________________________________
Companion´s Name and Passport Number:_______________________________________
Observation: _____________________________________________________________
City/ State/ Country: ___________________________________ Date: ___/___/________
____________________________________________
Signature of Cardholder
Please send this form filled by e-mail to [email protected] or
[email protected] in attention of Ana Cristina with a copy of credit card
(front and back side) and passport.