-
| From
: |
___________________________________ |
fax
: |
_______________________________ |
| To
: |
"Tenuta di Fiore"
- Lucciola S.r.l. - Todi - |
fax : |
_______________________________ |
.
| Related
to: |
Sejourn
at Villa Rocce, Località Fiore - 06059 Todi (Italia) |
|
from
____ /____ /____ to ____ /____ /____ |
.
| I, undersigned |
__________________________________________________________ |
.
authorize the
society "Tenuta di Fiore" - Lucciola S.r.l.,
located at Todi,
Piazza Jacobone 6, 06059 Todi (Italia) -
P.Iva : 01462100544
- CF : 02658350588 to credit the payment |
.
 |
for the advance |
of €uro _______________________________________ |
|
for the balance |
of €uro _______________________________________ |
.
With
Credit Card
.
|
Visa |
|
Diners |
|
MasterCard |
|
CartaSì |
.
| Cardmember Name
: |
__________________________________________________ |
| Cardmember address: |
__________________________________________________ |
| N° card : |
__________________________________________________ |
.
Expiration Date
: ____ / _____
.
| Date
: ___ /___ / ____ |
Card
Holder Signature : ______________________________ |
.
| I ask to send
the receipt of this payment at my name : |
.
| Mr./Ms. : _________________________ |
Fax n° _________________________ |
. |