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Name on Card:
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Email Address:
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Address Line 1:
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Address Line 2:
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Country:
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Passport Number:
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Date of Birth:
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Order Number:
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(Given to you
when confirming your order by fax or email.)
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I, hereby
authorize Excelsior Tailor to debit the sum of
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Baht only from my credit
card below
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Credit Card
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AMERICAN EXPRESS
MASTER CARD
VISA
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Card Number:
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Valid Until:
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Month: Year:
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For American Express,
please mention the four digit number appearing on the center right
hand corner.
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For Visa Card, Master
Card
please mention the three digit number appearing on the back side of
the card.
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Signature and
Date:
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Order once place cannot be Cancel
MAIL THIS FORM TO:
EXCELSIORFASHION@GMAIL.COM
115/1 @
Siamheritage Suriwongse, Bangrak
10500
Bangkok
Thailand
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Tel:
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+662
2342399
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Mobile:
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+668
12345923
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