From : ...........................................................................................

To: S A L A  D O N E  K H O N E

I hereby authorize SALA DONE KHONE to debit my credit card, the number of which and amount are stated below in order to secure my room reservation.

Card Holder's name: ……………………………… Surname: ………………………….…………

Passport n ° : ……………………………… Nationality: ……………………………………… .....

Card number: ……………………………… Verification Number................................................

Expiry date: ……………………................. Issued Bank: ………………………………….. .........

City: ………………………………………… Country: .................................................................

Amount in US $ :……………………………

Plus service fee: 5% (Five percent)   US $..................................................................

Grand amount in US $: .. ……………………………………………....... ( including service fee )

I ACKHOWLEDGE THAT THE ABOVE AUTHORIZED AMOUNT IS FOR A ROOM(S) DEPOSIT FOR ONE NIGHT/ROOM CHARGE AND THIS PAYMENT IS NON REFUNDABLE. CANCELLATION DUE TO EMERGENCY MAY BE CONSIDERED CASE BY CASE.

CARD HOLDER'S SIGNATURE …………………………………………………………................

N.B    KINDLY RETURN THIS SIGNED AUTHORIZATION FORM BY ATTACHED MAIL

          S   A   L   A      D   O   N   E      K   H   O   N   E

Khone Village, Khong District, Champasak Province, Lao PDR

Tel: +856 31 260 490 (Reservation)
Tel: +856 31 260 929 (Front Desk)
E-mail: saladonekhone@salalao.com, saladonekhone@gmail.com Website: www.salalao.com