Please print this credit card authorization form and send by Fax to : +62 361 283 164

 CREDIT CARD AUTHORIZATION FORM
 
To secure my reservation I hereby to authorize PT. KEMANG TRAVELINA WISATA (Bali-Travelina.com)  to charge my credit card as specified hereunder & Copy Credit Card + Copy Passport, attached. Being Charge for Accommodation / Tours, etc :
Hotel Name : __________________________________________________________
Tours / etc.   : __________________________________________________________
Check-In / Out       : __________________________________________________________
Total amount     : __________________________________________________________
Type of Card : __________________________________________________________
Card Number : __________________________________________________________
CVV : _________________________ (3 or 4 last digit not embossed).
Issuing Bank : __________________________________________________________
Expired Date : __________________________________________________________
Card Holder's Name : __________________________________________________________
Passport Number : __________________________________________________________
Date of Birth : __________________________________________________________
Billing Address

: __________________________________________________________

  __________________________________________________________

  __________________________________________________________

I understand that credit card payment are subject to  3% added bank service charge and calculated on the bank exchange rates the day processing. Also the Credit Card will charge 14 days (Low Season) and 30 days (High season) prior to arrival/date of tour request.  Differences in personal statement balances can occur and are due to the fluctuation with the Indonesian Rupiah (IDR) and bank processing time. We are not held responsible to these differences.

By sending this Credit Card Authorization Form I agree with balicantik.com Terms & Conditions.

Card Holder's signature :

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Front Copy Credit Card

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Back Copy Credit Card

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Copy Valid Passport Page

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Balicantik.com (Travelina Wisata Bali)
Phone: +62 361 284 151, Fax: +62 361 283 164
Jl. By Pass ngurah Rai No. 25 D, Sanur (80227) Bali - Indonesia
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