All Bali Villas

TOP BALI VILLAS

CREDIT CARD AUTHORIZATION FORM (CCAF)


I here authorize ,__________________________________________________________ to charge the following amount to my credit card as follows :

Card type :  
Cardholder’s Name :  
Credit Card No :                      -                      -                      -                     
CVV No :                      (the last 3 digits number at signature’s panel)
Expiry date :           /            (month/year)
Issuing / Providing Bank :  
Country of Issuing Bank :  
Passport No :  
Billing Address :  
Amount Debit :  
Description :  
Period date of stay :  
Total nights to stay :  

Cardholder's Signature:

 

 

 

______________________

 

Signature:

 

 

 

______________________

The form has been filled out should send back to us either via fax at:

62 361 776559 or scan and send via email in attachment therefore our company under name Bali Villa Beach shall authorize debit with amount base on invoice notified.

 


Click here to Print this Page! | Download Credit Card Form
Back