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CLICK HERE TO PRINT BOOKING
FORM THEN FAX TO +62 361 724128
Accommodation in Bali:
Room No:
Tel:
Vessel/Boat/Yacht Name:
Departure Date:
/ /
(mm/dd/yy) Program:
Total number of cabins required:
Remarks:
Vessel/Boat/Yacht/Cabin Cost:
Total Cost:
PASSENGER
DETAIL
Given Name:
Famiy Name:
Date of birth:
/ /
(mm/dd/yy) Passport No:
Nationality:
Home Address:
Zip Code:
Country:
Home Tel:
Home Fax:
Office Tel:
Office Fax:
Email Address:
Other Passenger(s):
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Family
Name
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Given
Name
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Date
of Birth
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Passport
No.
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I hereby apply for the aforementioned
Yacht & Cruise on the dates specified above and I authorize
payments of US$
be converted to Rp.
(Indonesian Rupiah)
to be charged to the credit card specified hereunder in accordance
with Bali Intaran.com 's
terms and conditions
as payment for Cruise/Yacht in Bali.
Card Type: Master* / Visa* / JCB* (*Delete
as applicable)
Name of issuing bank:
Card Number:
Expiry date:
Approval Code (for bank use only):
VISA/MASTER CVV
Number:
(security feature - Creditcard Validation Value)
VISA/MASTER BIN Number: (security feature - Bank Identification Number)
MASTER ICA Number: (security feature - International Card Association)
Card holders mother's name:
Cardholders Name:
Phone Number :
Billing Address:
Cardholders Signature:
Thank you for booking with
Baliintaran.com. Remember to fax the completed form
as well as a copy of passport and credit card (both side) to +62 361 724128
Once your credit card has been approved your confirmation and voucher
will be issued.
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