| CREDIT CARD FORM BY FAX |
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| TO : Bali Villa Collection |
| Facsimile No. : +62 361 7805418 |
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| I am ,________________________________________ |
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. |
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| Card Number : ____________________________________________ |
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| Expiry Date : _______________________________________ |
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| Cardholder's Name : _______________________________________ |
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| 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: |
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| Telephone No. : ___________________________________ |
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| Facsimile No. : __________________________________________________ |
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| Email Address : _______________________________________________ |
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| Signatures : _____________________________________ |
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