Fax Form

Please fill out this form and print it out.
Once printed, sign the bottom and fax to +61-7-40311210.
No information will be recorded or sent by filling this form out.

fields marked with * are mandatory

*Card holders name:
*Your email:
Your phone:
Your fax:
*CREDIT CARD NUMBER:	- - -
*EXPIRY DATE mm/yr:	/
*CREDIT CARD TYPE:
*AMOUNT AUTHORISED:	AUD$
Trip you are booking:	For example: 5 Day Learn to dive with Deep Sea Divers Den for 2 people. John Smith and Jane Smith.
Special Requirements:	For example: any dietry requirements.
*Preferred trip start date:		Dive Trip
Pick up from:

*Card Holders Signature
Date:	/ /	(dd/mm/yy)
By sending this credit card authorisation, I confirm that I know and acknowledge the booking terms and conditions and authorise DIVE DIRECTORY to use the above credit card to pay for travel services purchased by me.
No information will be recorded or sent by filling this form out or printing it.