Alternativly fill in the form, sign it, then scan and email to
Name of Villa :                                                                          Bali - Indonesia.

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

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

Total number:  Adults:          Children:         Total number of nights required:                   

Rental Fee: US$              per night.  Minimum Deposit 30% US$                Balance US$                   

If you have any special requests such as a meal upon arrival, a list of groceries you need (including wines or beers) or to reserve tours or activities then please include these on a separate fax or e-mail.

I/we hereby apply for the aforementioned Villa on the dates specified above and I/we authorize payments to be charged to the credit card specified hereunder in accordance with Bali Vacation Rental terms and conditions as payment for accommodation on 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. Bali Vacation Rental Use Only (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 (where the CC statements go to)                                                                           


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.