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TO SECURE YOUR BOOKING PLEASE COMPLETE THIS BOOKING FORM 
THEN FAX TO +62 361 84 75 943

Type of Jump: TANDEM SKYDIVE FROM 10,000ft.
Tour Date:                                                       2011 / 2012
Total number of guests:  Adults              Children over 14:                   
Amount payable per person US$ 199
Total amount payable US$                            I wish to pay with: CASH / CREDIT CARD* 
Name of Client(s)                                                                                                                   Hotel/Residence:                                                                                 Room No.                  

*I/we hereby apply for the aforementioned Tandem Skydive on the date specified above as per
Skydive Bali’s Terms & Conditions (see overleaf) and *I/we authorize payment be charged to the credit card specified below as payment for the aforementioned Skydive.
    Signed:                                                                                                                       
    Print Name:                                                                                                                 

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 Tandem Skydive.

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

Card Number:                                                                                                              

Expiry date:                                                                                                                 

Last 3 digits in signature section on back of card (if any):                                       

Name of issuing bank:                                                                                                  

Cardholders Name:                                                               Date of Birth:        /       /     

Cardholders Signature:                                                                                                        

E-mail Address:                                                                                                                      

Passport number:                                  Expiry date:                   Nationality:                          

Billing Address (where credit card statement goes to)                                                                                                                                                                                                                                                                                                                                                            

Approval Code (for bank use only):                                                                                      

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.