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Credit Card Online Form

SCB Internet Payment System (SIPS)
Important!! Please furnish full name
First Name :  (Card Holder Name)
Last Name :
Important !! Pls furnish complete e-mail address so that our reply could reach you
Email :  (Correspondence E-mail address)
Address :
City :
Province/State :
Zip Code :
Country :
Phone :
Fax :
Description of Service :  (Hotel Name, Tour, Package, Air Ticket, etc.)
Reservation Number :  digit only (i.e. 99999)
Period :  (dd/mm/yy – dd/mm/yy) No more than 20 valid number
Amount pay :  digit onlyNO Comma! (i.e. 99999)
Currency :

Please click send button to continue the second page for credit card details !!!
Please contact us if you encounter any difficulties sending this form.