-
| From : |
______________________________ |
fax |
_________________________ |
| To : |
"Tenuta di
Fiore" - Lucciola S.r.l. - Todi - |
fax |
__________________________ |
.
| Related
to: |
Sejourn
at Tenuta di Fiore, Località Fiore - 06059 Todi (Italy) |
|
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 number : _______________________ |
. |