Girikand.com

Please fill in the form below, take a print-out and fax it to us at +91 20 2565 3577. We apologies for any inconvenience this may cause you, however we assure you that this is in your best interests. It will help ensure your security. If you unable to print this form right now, please visit the Flights page on www.girikand.com. A link to this page is available this page.

To,
Girikand Travels Private Limited
759/90 B, Bhandarkar Institute Road,
Deccan Gymkhana, Pune (India)- 411004.

Fax : +91 20 2565 3577
Tel : +91 20 2565 9970 / 2565 3570

Please fill in the form below

Kind Attention.

I, The undersigned, Mr. / Mrs. / Ms. / Dr.

hereby authorise Girikand Travel Pvt. Ltd. to Debit my credit / debit card number

Name as on Card :

Expiring on : / /

For the amount of :
( INR / USD )

Amount in words :

Towards : ( State reason )

I hold a : MasterCard Visa

My passport details are :

Passport No. :	Place of issue :
Date of issue :	Date of Expiry :
Date of birth :

Cardholder's Signature :

Attached : Photocopies of both sides of credit card.