OneBaliVillas.com | Credit Card Autorization form

Please print this credit card authorization form and send by Fax to : +62 361 974923

CREDIT CARD AUTHORIZATION FORM

To secure my reservation I hereby to authorize OneBaliVillas.com (Kunang Kunang Paradise Bali) 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	: VISA or MASTERCARD
Card Number	: __________________________________________________________
The Card Identification Number (Card ID) last three number at the back of card	: _________________________
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 OneBaliVillas.com Terms & Conditions.

Card Holder's signature :

Front Copy Credit Card

Back Copy Credit Card

Copy Valid Passport Page