masan vacation bali

I hereby authorize: Villa(s) ЕЕЕЕЕЕЕЕ. to charge my credit card as specified here under and Copy of Credit Card + a Copy of my Passport according to your TERMS AND CONDITIONS in order to pay our reservation at Villa(s): ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ..

Arrival date	:
Departure date	:
Total Stay	:

CREDIT CARD AUTHORIZATION FORM

Card Holder's Name	: _______________________________________________
Type of Card	: _______________________________________________
Card Number	: _______________________________________________
CVV	: ____________ (3 last digit numbers which not embossed).
Issuing Bank	: _______________________________________________
Expired Date	: _______________________________________________
Passport Number	: _______________________________________________
Date of Birth	: _______________________________________________
Nationality	: _______________________________________________
Billing Address	: _______________________________________________ _______________________________________________ _______________________________________________
Non-refundable Full Amount in USD	:

Card Holder's signature :

_________________________

jalan uluwatu gang soka 28 b. kelan abian tuban- bali 80361.

Click here to Print this Page!