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.

Booking Ref Number: TOCS
Your Consultants Name: 
Booking Name:
Booking Name must be as shown on current confirmation or invoice
Billing Address:
Street:
City:
State:
Postal Code:
Country:
Your Email Address:
Payment Value: A$ (Australian Dollars)
Credit Card Type: Visa, Mastercard, Diners and Amex.
Please note that fees apply to all credit card transactions:
1% - Mastercard, Visa
3% - American Express, Diners
Card Holder Name:
Card Holder Name must be as shown on your credit card
Card Number:
Expiry Date: MM   YY
ID Code: (AMEX Only)



Signature: .............................................................................



Authorisation: Submitting this payment request authorises Travel Online to debit your credit card for the amount shown above and that you have read and agreed to the Travel Online Terms and Conditions of Booking. An updated confirmation reflecting payments made will be sent to you following the processing of each payment.

Travel Online (ACN 063 119 620)
Level 1, Cnr Graham Street & Gardner Close
Milton, Qld, 4064, Australia

Ph: 61 7 3512 8100     Fax: 61 7 3876 4645     Email: info@travelonline.com

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