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BOOKING FORM & CREDIT CARD PAYMENT AUTHORITY
TO SECURE YOUR BOOKING PLEASE COMPLETE & FAX TO +62 361 84 75 943
Name of Tour or Activity:
Tour required on date: 2011/2012
Total number of guests: Adults Children:
Amount payable per person US$
Total amount payable US$
*I/we hereby apply for the aforementioned tour or activity on the dates specified above and *I/we authorize payment be charged to the credit card specified hereunder.
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 tour or activity in Bali.
Card Type: Visa* / MasterCard* (*Delete as applicable)
MasterCard ICA Number or Visa 4 digits: (MC - back of card, usually bottom right corner - Visa 4 digits on front below CC No.)
Expiry date: / /
Last 3 digits in signature section on back of card (if any):
Name of issuing bank:
Cardholders Name: Date of Birth: / /
Passport number: Expiry date: / / Nationality:
Billing Address (where the CC statements go to)
Approval Code (for bank use
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.