Africa Centre Credit Card Authorisation Form - Master / Visa

Please PRINT, COMPLETE, SIGN and FAX to: (+27 86 6000 383 / +27 86 5874 730) or SCAN and email (afrcentr@global.co.za) to us together with a copy of the front and the back of the authorised credit card.

NOTE: Please put what the payment is for - Type of Accommodation + Date of Arrival / Tour Name and Date of Departure / Number of People

Card Type  
Card Holders Name  
Email Address  
Nationality  
Passport Number                                
Card Number                                
Last 3 Digits on Back of Card            
Card Expiry Date        

NOTE: Please put what payment is for - COMPANY / TOUR CODE & DATE / TIME OF DEPARTURE

PAYMENT FOR:

 
 
 

I hereby authorise Africa Centre International CC to debit my Credit Card. I am aware that a 5% administration charge will be levied.

Total Rand Amount
ZAR
           
-
   
Rand Amount in Words : ZAR
 
Authorised Signature
of Holder
Date                

Please PRINT, COMPLETE, SIGN and FAX to: +27 11 894 4857