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|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)
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:
Billing Address (where the CC statements go to)
Thank you for booking with
Bali Vacation Rental.