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PAYMENT FORM Please complete the following form and return it by fax or mail to: Travel agency VISIT LITHUANIA L.Stuokos-Guceviciaus 1, LT-01122, Vilnius, Lithuania Fax: +370 5 2625 242 Surname _________________________________First Name__________________________ Ref No ______________________________________________ Date of service _____________________________________________________ Charge __________________ to my: ¨ VISA Card £ MasterCard Card Number ______________________________________ Expiry date______________________________ Security code____________ By signing this form I authorize VISIT LITHUANIA to charge the above credit card for the balance of my account for services ordered. I certify that I have read and do accept the conditions of reservation and cancellation rules. SIGNATURE: |









