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.
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