CREDIT CARD DETAILS BY FAX FORM
To : TopBaliVillas.com
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 |
: |
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| Card Number |
: |
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| Expiry Date |
: |
|
| Cardholder's Name
|
: |
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| 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. |
: |
|
| Facsimile No. |
: |
|
| Email Address |
: |
|
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