Bali Villas Holiday

CREDIT CARD DETAILS BY FAX FORM

To :Balivillasholiday.com
Facsimile No. : +0361 271060

I,_____________________________________________________________ have sent you a villa reservation request via the Internet/e-mail, without my credit card details on the form.

These are my credit card details, which I hereby authorize to be used for the deposit and balance of account / any cancellation charges in respect of the villa(s) I have asked you to reserve for me.

Type of Card	:
Card Number	:
Expiry Date	:
Cardholder's Name	:
Cardholder's Signature	:
Notes	:

If you have not received my reservation request yet and / or need me to send you a copy of my passport, please contact me on:

Telephone No.	:
Facsimile No.	:
Email Address	: