Bali-Travel-Online.Com - Payment form

PAYMENT FORM

CREDIT CARD INFORMATION FAX FORM
This form is provided by Bali-Travel-Online.Com (an internet marketing development of Cita Travel Service Ltd - Bali).

Bali-Travel-Online.Com
Cita Travel Service Ltd
Cottage Arcade, The Grand Bali Beach Hotel
Sanur - Denpasar
Bali - Indonesia

Phone : ++62 361 282694
Phone : ++62 361 288511 ext 1358

Fax : ++62 361 282694

Please print this form, fill it out with all required information then FAX them to us after receiving our confirmation of rooms, transfers, airlines ticket, package arrangement, local excursions, meals, etc......to our office in Bali : ++62 361 282694. Any transaction using credit card will add 3% from the total bill for the local bank administration fees.

Hotel Name :________________________________________

City : __________________

Package Arrangement :_________________________________

Total Nights/Package Duration _______________

Guest's Name : _______________________________________

Total Person :____________

Type of room/Package ________________________________

Extra Charge : ___________

Your Arrival Date : Day_____/Date____/Month____/Year____

Arrival Flight_____________

Your Departure Date : Day____/Date____/Month____/Year____

Departure Flight__________

Cardholder's name : __________________________________________________________
(As it appears on the card)

Card Number : ______________________________________
Three small number state at the back of your card: ___________

Expire Date _____________

(VISA)		MASTER CARD		AMEX CARD

I hereby authorize Bali-Travel-Online.Com (Cita Travel Service) to charge my credit card at a total amount of _________ US$
(__________________________________________________
__________________________________________________)

Passport Number :______________
We may need copy of your passport!

Cardholder's address : ________________________________
__________________________________________________

Passport issued date:
______________________
Passport Expire date:
______________________

City
__________________

State/Province
__________________

Country
_____________

Email Address : _____________________________________________________________

Phone : (country code______) (area code_______) (phone number________________)

Signature : ____________________________________
As it appears on the card

Signed date :

_____________________

We will let you know if our bank requires further information, copy of your card and passport to be faxed to our office for their reference.