|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.
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)
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:
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.