| I,
authorize Siam Media Online Co., Ltd. of 653 Soi Jaransanitwong 67, Jaransanitwong Road, Bangplad, Bangkok 10700, Thailand. |
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to charge the sum of : Baht |
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TO:
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| Card Number : | |
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Visa or Master 3 digits
 :
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Amex
4 digits  :
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Expiry Date (mm/yy): / |
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My name as appear on the card is : |
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| Card Holder’s Billing Address:
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The above mentioned charge is for : |
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Card Holder’s Signature :_________________________ Date (dd/mm/yy): / / |
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| Cardholder's Fax No : | |
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KINDLY FILL OUT THIS FORM ALONG WITH YOUR SIGNATURE, PRINT OUT AND FAX BACK TOGETHER WITH PHOTOCOPIES OF YOUR CREDIT CARD (front and back) TO (66-2) 881-1019 |
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Visa
Master Card
Amex