Dreamscapes Development Co., Ltd.
Whispering Palm
1/23 Moo 2, Bophut, Kohsamui, Suratthani 84320 Thailand
Mobile: +66 81 832 5895
Fax: +66 77 484 488
E-mail:
info@dsdsamui.com
Payment
Form
I would like to proceed with my reservation
Personal Information
Mr.
Mrs.
Miss
*
First Name :
*
Last Name :
*
Passport No :
*
Telephone : *
E-Mail
: *
Fax No :
Reservation / Order No:
(This confirmation number has been sent to you
by e-mail)
Address :
House Number : *
Street : *
City : *
Post Code :*
Country : *
I Authorize Dreamscapes to :
Deduct the sum of :
*
THB
US $
€
�
CHF
(Verify amount from E-mail)
From my credit card : *
C
redit card
Visa
Master Card
Credit Card No: *
Expiry date : *
mm/yy
Thank you for your payment.
All payments will be charged in lo
cal currency THB (Thai Baht) at current rate of exchange.
or