The Republic of Xanadu-du Ltd
75 Elmdale Road
Liverpool L9 2BH
United Kingdom
email: briandouggg@gmail.com
ORDER / ENQUIRY FORM: 8 August 2008
| Name |  |
| Address | |
| City | |
| County | |
| Country | |
| Postcode |  |
| Phone | |
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| Dates Required | |
| No Nights | No Rooms | Flat Location |
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Royal Quay, Liverpool |
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South Ferry Quay, Liverpool |
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Prince's Dock, Liverpool |
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Torrevieja, Spain |
CARD DETAILS
Note: we do not keep credit card details on any computer system or database.
| Card Type | Visa | Mastercard | American Express |
| Valid From |  |
Expiry Date | |
| Card Number | |
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| Security Code | |
Issue Number | |
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I hereby authorise The Republic of Xanadu-du Ltd to debit £  from the credit card detailed above |
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| Signature | |
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Print this form, complete your details, sign the form, and fax it to
0151 474 7931 (international customers: 0044 151 474 7931).
When your payment has been processed, we will email a receipt to you.
Questions? Call 07711779248