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Fax Back Form
This is a printable form and is not intended for submitting online. Please complete this form, print it, sign it, and fax it to 07 3876 4645 from within Australia, or to 61 7 3876 4645 from outside Australia. Online payments are available through our secure payment facility.
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Booking Ref Number: |
TOCS
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| Your Consultants Name: |
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Booking Name:
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Booking Name must be as shown on current confirmation or invoice
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Billing Address:
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Your Email Address:
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Payment Value:
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A$
(Australian Dollars)
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Credit Card Type: |
Visa, Mastercard, Diners and Amex.
Please note that fees apply to all credit card transactions:
1.98% - Mastercard, Visa
4% - American Express, Diners
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Card Holder Name:
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Card Holder Name must be as shown on your credit card
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Card Number:
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Expiry Date:
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MM
YY
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ID Code:
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(AMEX Only)
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Signature:
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.............................................................................
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| Authorisation:
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Submitting this payment request authorises Fusion Holidays to charge your credit card for the amount shown above and that you have read and agreed to the Fusion Holidays Terms and Conditions of Booking. An updated confirmation reflecting payments made will be sent to you following the processing of each payment.
Fusion Holidays
Level 1, Concept Building, Cnr Graham Street & Gardner Close
Milton, Qld, 4064, Australia
Ph: 61 7 3512 8150 Fax: 61 7 3876 4645
Email: info@fusionholidays.com.au
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