Aegialis School of Yoga – 11 Day – Aegialis Hotel Authorization Platform

Name*
Email*
Mobile Phone*
Occupancy Type
I'm interested in the following package
Number of course days: 11
Number of nights: 12
I'm interested in the following package
Number of course days: 11
Number of nights: 12
I'm interested in the following package
Number of course days: 11
Number of nights: 12
I'm interested in the following package
Number of course days: 11
Number of nights: 12
Payment
- Full payment (100%)
- Deposit payment (30%)
Total Cost*
Payment Details 💳 🔒
Card Type*
- Mastercard
- Visa
- American Express
Credit Card No.*
Credit Card No.*
Name on Card*
Card Expiration*
CVV*
Where to find the CVV or CID
CID (AmEX)*
Where to find the CVV or CID
Authorized Amount*
I authorize Aegialis S.A. to charge my account as above:    
Electronic Signature*
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Timestamp
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IP
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UniqueID