Credit Card Form

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JL GN Agung GG Indus No.4 Denpasar Bali 80118 Indonesia ++ 62 361 412981 ++ 62 361 421583

Please print this credit card authorization form and send

by Fax to : (++ 62) 361 421583

CREDIT CARD AUTHORIZATION FORM

VISA & MASTER CARD ONLY

To secure my reservation, I hereby to authorize PT AIDA INDONESIA DEWATA TOURS (alliance-indonesia.com/balidives.com/indobalitravel.com) to charge my credit card as specified hereunder & Copy Credit Card + Copy Passport, attached. Being Charge for Accommodation / Tours, etc :
Hotel Name	: ___________________________________________
Tours / tickets /etc.	: ___________________________________________
Check-In / Out	: ___________________________________________
Total amount	: ___________________________________________

Type of Card	: ___________________________________________
Card Number	: ___________________________________________
Issuing Bank	: ___________________________________________
Expired Date	: ___________________________________________
Card Holder's Name	: ___________________________________________

Passport Number	: ___________________________________________
Date of Birth	: ___________________________________________
Billing Address	: ___________________________________________ ___________________________________________ ___________________________________________

I understand that credit card payment are subject to 3,5 % 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 Alliance-Indonesia.com Terms & Conditions .

Card Holder's signature :

Front Copy Credit Card

Back Copy Credit Card

Copy Valid Passport Page

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