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CLICK HERE TO PRINT BOOKING
FORM THEN FAX TO +62 361 724128
Arrival Flight:
Time:
Pick-up Service:
(yes/no)
Check-in Date:
/ /
(mm/dd/yy) Check-out Date:
/ /
(mm/dd/yy)
Hotel to Stay:
Room Type:
Total of Room: Remarks:
Room Price: Total
Cost:
PERSONAL
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 Guest(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
Hotels in Bali 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 accommodation in Bali.
Card Type: AMEX* / Master* / Visa* / JCB* (*Delete
as applicable)
Name of issuing bank:
Card Number:
Expiry date:
Approval Code (for bank use only):
AMEX/VISA/MASTER CVV
Number:
(security feature)
Cardholders Name:
Cardholders Signature:
Credit Card Billing Statement Address:
Thank you for booking with
Baliintaran.com. Remember to fax the completed form to +62 361 724128
Once your credit card has been approved your confirmation voucher
will be issued.
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