CREDIT CARD DETAILS BY FAX FORM
To : The Bali Private Villas.com
Facsimile No. : +62-361-974923
I,_____________________________________________________________ have sent
you a villa reservation request via the Internet/e-mail, without my credit
card details on the form.
To secure my reservation I hereby to authorize http://www.thebaliprivatevillas.com (Bali Trip ) to charge my credit card as specified hereunder & Copy Credit Card + Copy Passport, attached. Being Charge for Accommodation / Tours, etc .
| Type of Card |
: |
(.....) Visa or ( .... ) MasterCard |
| Card Number |
: |
__________________________________ |
| Expiry Date |
: |
__________________________________ |
The Card Identification Number (Card ID)
last three number at the back of card |
: |
_______________ |
| Total Amount |
: |
_______________ |
| Issuing Bank |
: |
__________________________________ |
| Passport number |
: |
__________________________________ |
| Date of Birth |
: |
_______________ |
| Billing Address |
: |
__________________________________ |
| Cardholder's Name |
: |
__________________________________ |
| Cardholder's Signature |
: |
__________________________________ |
| Notes |
: |
__________________________________ |
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I am sending you a copy of my credit card (front & back) and a copy of my passport, if you have not received my reservation request yet, please contact me on:
| Telephone No. |
: |
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| Facsimile No. |
: |
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| Email Address |
: |
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