Bali Villas Holidays - Our Booking Form

Salutation :	Other:
Family Name :
Given Name(s) :
Business Title :
E-mail Address :
Date of Birth :
Nationality :
Address :
City :
State :
Zip :
Country :
Home phone :
Phone :
Fax :

Total Number of guests in your party :

	Guest Name	Age		Guest Name	Age
1.)			7.)
2.)			8.)
3.)			9.)
4.)			10.)
5.)			11.)
6.)			12.)

Flight Details

Arriving with flight Number		Date of arrival
Departing with flight Number		Date of departure

Villa Details

Name of Villa :
Commencing Date :
Ending date :
Total Number of Nights :

Payment Details

Deposit	USD
Balance	USD
Total Due	USD

I declare that I am over 18 years of age and that this booking is made in accordance with the terms and conditions of balivillasholidays.com. I agree that I have read and understand these terms and conditions.

Signature of Guest : Date :

Credit Card Authoriziation

I, the undersigned, hereby authorise Bali Villas Holidays
- a division of PT De Vishnu - to debit my credit card as follows

VILLA TO BE BOOKED :
Name of Person Making the reservation :
Month of Booking :
Amount authorised (plus merchant surcharge) :
Name as is appears on the card :
CREDIT CARD NUMBER :
EXPIRATION DATE of Card :	mm/yy
Verification Number :	(3 digit )
CARD TYPE :
BANK ISSUED :

Billing Address Of Card

Address :
City :	State :
Zip/Postal Code :
Country :
Contact Phone number for cardholder :
Signature of Cardholder :	Date :

Thank you for booking with Bali Villas Holidays.
Please print this form, and faxing to Bali Villas Holidays on +62 0361 270 465
along with a copy of your passport

Once your credit card has been approved, we will issue you with a
Booking confirmation.

Please complete this form and fax to Bali Villas Holidays.
Bookings are not valid without receipt of this form and deposit approval.

Fax To +62 361 270 465

FOR OFFICE USE ONLY

DATE CHARGED : AMOUNT CHARGED :

balivillasholidays.com
A division of PT De Vishnu
Jl Betngandang I No 7A, Sanur, Bali
T + 62 0361 7424973 F +62 0361 270465
E: booking@balivillasholidays.com W: www.balivillasholidays.com