CLICK HERE TO PRINT BOOKING FORM THEN FAX TO +62 361 84 75 943
 

Name of Hotel:                                                                                                                     

Check in date:           /        /         Flight Number                          Arrives             :         hrs.

Check out date:         /        /         Flight Number                          Departs            :         hrs.

Total number of rooms required:                      Total number of nights required:                

Total number of guests: Adults           Children:                 Number of extra beds                

Room charge: US$             per room per night. - Total amount US$                                    

I hereby apply for the aforementioned Hotel Room(s) on the dates specified above and I authorize payments to be charged to the credit card specified hereunder in accordance with Indovillas terms and conditions as payment for accommodation in Bali.

Signed:                                                                                                                                       

Print Name:                                                E-mail address:                                                        

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 accommodation in Bali.

Card Type:    Visa* / MasterCard* (*Delete as applicable)

Card Number:                                                                                                                                 

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:         /        /        

Cardholders Signature:                                                                                   

Passport number:                          Expiry date:                          Nationality:                                    

Billing Address:                                                                                                                              

                                                                                                                                                         

Thank you for booking with Bali Vacation Rental.
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.