..............................DATE

......................................................................................................NAME OF CARDHOLDER

.................................................................................................................................ADDRESS

...........................................................CODE.........................................COUNTRY

..........................................................................................................NAME OF PASSENGER

...................................CONNECTION OF PASSENGER TO CARDHOLDER FAMILY/FRIEND

_________ _____________________CHARGED FOR

(____________________________)  ________AMOUNT

TYPE OF CARD: VISA MASTER DINERS AMERICAN EXPRESS

DETAILS

..................................................................................................CARD NUMBER

....................................................................................................EXPIRY DATE

......................................................................................................NAME AS SHOWN ON CARD

....................................................................LAST 3 DIGITS OF NUMBER ON BACK OF CARD

...................................................ID NUMBER ................................................. OR PASSPORT NO

  I agree to be bound by the Hebrew section bellow.   - תנאים והגבלות אחריות    

..........................................CARDHOLDERS AUTHORITY TO DEBIT AS ABOVE

(SIGNATURE)............... .................................................AUTHORITY NUMBER: ............ (OFFICE USE ONLY)