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|CRUISE BOOKING FORM & CREDIT CARD PAYMENT AUTHORITY|
|Name of Vessel/Ship:
Cruise date, From: / / Until: / / Code:
Total number of berths required: Total guests: Adults F; Children
Amount payable per passenger US$ Total amount payable US$
A minimum deposit of 30% is required in order to secure this booking
and the balance due
I/we hereby apply for the aforementioned cruise on the dates specified above and I/we authorize payment to be charged to the credit card specified hereunder in accordance with Indovillas terms and conditions as payment for the above cruise.
Print Name: e-mail:
Telephone: Home Work/Mobile:
Credit Card Payment in favor of PT. Indovillas Bali - I hereby authorize the payment of US$ be converted to Rp. (Indonesian Rupiah), and charged to my credit card as payment for the aforementioned Cruise.
Card Type: Visa* / MasterCard* (*Delete as applicable)
Expiry date: / / Approval Code (for bank use only):
Last 3 digits in signature section on back of card (if any):
MasterCard ICA Number or Visa 4 digits: (MC - back of card, usually bottom right corner - Visa 4 digits on front below CC No.)
Name of issuing bank:
Cardholders Name: Date of Birth: / /
Passport number: Expiry date: / / Nationality:
Billing Address (where the credit card statements go to):
Remember to fax the completed form to +62 361 84 75 943.
Once your credit card has been approved your confirmation voucher will be issued.