Thai Batik Shop & Gallery E-FAX Form

Name of Buyer
Street Address
City, State / Province
Country & Postal Code

Telephone Number

Country Code

City Code

Number

Fax Number

Country Code

City Code

Number

Email Address
Description of the payment / purchase transaction

I authorize Thai Batik Shop and Gallery to charge my

VISA MasterCard JCB SCB

NUMBER on Credit Card

Last 3 digit number appearing on signature panel
Card Holder's Name Expiry Date

To: Siam Commercial Bank, Phi Phi Branch

Account Name: Veerepoj Tanaunyaporn

Account Number: 794-2-00668-5
This is to give my permission for Thai Batik Shop & Gallery, Thai Batik & Phi Phi Gallery, T. Ao-Nang, A. Ao-Nang, Krabi 81000, Thailand to use this signed fax as a substitute in place of my actual credit card for the purpose of making a payment transaction that will be applied to my credit card.

The TOTAL Credit Card Payment Amount (not to exceed) .00 Baht Dollars
Same Amount written in words .00

SIGNATURE (as used on credit card) ___________________________ DATE ________/________/_____

PLEASE PRINT THIS FORM NOW

Fax this FORM directly to
Thai Batik Shop & Gallery, Fax: (66) 076.263.996 Please keep your printed copy for your records.

Refund Policy: Refunds are limited to exchange of product only. Defective products must be returned to us within 30 days
of receipt of product. Return postage paid by buyer.
Delivery Policy: Shipment will be made within 15 days of receipt of payment from buyer.

THANK YOU Please use your back arrow to return to the Thai Batik Shop & Gallery main page.