| Please print this credit card authorization form (click the print icon above) and send to : Fax: +30 22730 23205 |
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| Samos Hotel: Virginia Samos Hotel Rooms, Studios & Apartments - Family Hotel on Samos Island, Greece | |
| Last Name | : ___________________________________________ |
| First Name | : ___________________________________________ |
| Check-In Date | : ___________________________________________ |
| Check-Out Date | : ___________________________________________ |
| Number of People | : ___________________________________________ |
| Number of Nights | : ___________________________________________ |
| Rooms: Qty./Type | : ___________________________________________ |
| Total Amount | : ___________________________________________ |
| Type of Card | : ___________________________________________ |
| Card Number | : ___________________________________________ |
| Issuing Bank | : ___________________________________________ |
| Expiration Date | : ___________________________________________ |
| Card Holder's Name | : ___________________________________________ |
| Telephone | : ___________________________________________ |
| Address | : ___________________________________________ |
| : ___________________________________________ | |
| : ____________________ Country _______________ | |
| Special Requests | : ___________________________________________ |
| : ___________________________________________ | |
| : ___________________________________________ | |
| : ___________________________________________ | |
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A deposit of 30% of your stay will be debited from your credit card at the time of booking, please see our terms and conditions to see our cancellation policy. By Submitting this form, you hereby agree to the Virginia Hotel terms and conditions. Card Holder's signature :
Date: |
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Fax form
