BALI VACATION VILLA

CREDIT CARD DETAILS BY FAX FORM


To : BALIVACATIONVILLA.COM
Facsimile No. : +62 361 702299


I,_____________________________________________________________ have sent you a villa reservation request via the Internet/e-mail, without my credit card details on the form.

These are my credit card details, which I hereby authorize to be used for the deposit and balance of account / any cancellation charges in respect of the villa(s) I have asked you to reserve for me.

Type of Card :
Card Number :
Expiry Date :
Cardholder's Name :
Cardholder's Signature :
Notes :

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. :
Facsimile No. :
Email Address :

 

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