203 612 2821, 203 595 5333


To: Mypayanam Please send signed fax to 203 595 5333 along with Creditcard front and back and govt issue id

Please check the itinerary for names of passenger. Mypayanam is not responsible for transit and travel Visa Requirements of any kind

I , (Credit card holder's Name) request Mypayanam to make the following date changes noted below and authorize Mypayanam to charge the amount listed below.
Total Amount (USD):
1. Cardholder’s name as it appears on the credit card:
2. Cardholder’s billing address including Zip Code
Street: City:
State: Zip:
3. Cardholder’s phone number:
4. Email:
5. Credit Card Number:
6. Exp Date:
CVV (at the back of card):

Is the cardholder traveling?

Is the cardholder paying for more than one purchase?

If yes, then the names of the passengers and their relationship with the cardholder:

Total Amount (if different from the above) in USD:
Departure Date changed From : To:
Return Date changed From : To:
Yours truly
Signature here: x______________________ Date: _______________
Please sign and fax along with credit card front and back, and govt. issued id ex. Drivers license to 203 595 5333