Cruise Booking Form

CRUISE BOOKING FORM
Bali Intaran Tours

CLICK HERE TO PRINT BOOKING FORM THEN FAX TO +62 361 723990

Boat Name		Cruise Program
Departure Date		Total of Passenger
Remark		Total cost

Passenger Detail No. 1		Passenger Detail No. 2
Family name	:	Family name	:
First name	:	First name	:
Sex	:	Sex	:
Birth date	:	Birth date	:
Nationality	:	Nationality	:
Passport number	:	Passport number	:
		please note: don't fill in when same as pax 1
Home Address	:	Home Address	:
City	:	City	:
Area Code	:	Area Code	:
Country	:	Country	:
Phone home	:	Phone home	:
Fax	:	Fax	:
e-Mail	:	e-Mail	:
Emergency contact	:	Emergency contact	:
Hotel in Bali	:	Hotel in Bali	:

Additional Passenger Details
Family name	First name	Sex	Birth date	Nationality	Passport No

I hereby apply for the aforementioned Yacht & Cruise on the dates specified above andI 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)

Issued Bank Name :

Credit Card Number:

Card Expiry date: Approval Code (for bank use only):

CVV Number: (security feature - Creditcard Validation Value)

Cardholders Name:

Card holders mother's name:

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 723990
Once your credit card has been approved your confirmation and voucher will be issued.