CREDIT CARD DETAILS BY FAX FORM
To : paradisebalivillas.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 |
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| Card Number |
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| Expiry Date |
: |
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| Cardholder's Name
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: |
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| Cardholder's Signature |
: |
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| Notes |
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If you have not received my reservation request
yet and / or need me to send you a copy of my passport, please contact
me on:
| Telephone No. |
: |
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| Facsimile No. |
: |
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| Email Address |
: |
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