Signature –On- File -------Authorization Form FOR
Credit Card Authorization Form
Please fill and email back to:
Email id : praveenkokne@
Tel.: 8826266168
I, _______________________________________________________________ (name of card holder) hereby authorize Elbon Conferences & Events Pvt. Ltd., New Delhi, India, to charge the following American Express card for travel related services being rendered to (tick which applicable) me (card holder) / my clients (if agency paying on behalf of clients, please use corporate card or agency owner card).
|Card Number : |
|__ American Express : __________________________________________________________ |
|Card Security Code : _______________________ Expiry Date : _________________________ |
|(Security Code - AMEX - 4 digits on front face) |
|Amount Charged: US$ _____________ at the exchange rate of INR ______ = 1 US$ |
|Total Indian Rupees. _______________ |
|Card Member Name : ___________________________________________________________ |
|If services are not for card holder, then name of clients for which the services are booked : |
|_____________________________________________________________________________ |
|Card Holder Billing Address: _____________________________________________________ ___________________________________ Mobile No. : |
|_______________________________ Passport no. : _________________________ Date of Birth : ____________________________ |
|Tel no. Residence : __________________________Office : ________ |
|Present Address: ____________________ |
With this form please also fax a copy of your passport. These rules are followed by credit card companies in India for transactions where the card holder is not personally present and are meant to prevent cards from being misused and is for your own safety.
I understand that the record of charges in respect of goods services received / availed- submitted by you or airlines whose services have been utilized to TRS, American Express Bank Ltd. Issuing Bank will neither bear my signature nor the imprint of my card, and therefore undertake to unconditionally honor and pay without demur and contestation, the said charges, as and when I am billed the same by American Express.
Signature as it appears on card: _________________________________________________________
Name: _____________________________________________________________________________
Date: ______________________________________________________________________________
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