Full name of credit card holder: _________________________________________

Billing Address:

Services and dates:

Nationality: _________Passport Number_________________

Credit Card Number: _________________________

Visa MasterCard Diners Amex Discover:___________

Expiry date: _______Digits on back of credit card:____

This is to authorize Jerusalem Eternal Tours, a Division of Eshet Irgun to charge my

credit card in the amount of: USD$ __________ for the above tourist services in

Israel.

I understand that there is a 2% surcharge for this credit card transaction.

Signature:_________________________________________

Please fill in, sign & return by scan or fax:

Attention - Daniel Decker

Direct fax no. +972-73-3271137

[email protected] www.Jerusalem-Eternal-Tours.com