Bali villas for rent
 
CREDIT CARD AUTHORIZATION FORM (CCAF)
 
I here authorize,  
to charge the following amount to my credit card as follows :
     
Card type :  
Cardholder's Name :  
Credit Card No :                      -                      -                      -                     
CVV No :                        (the last 3 digits number at signature's panel)
Expiry date :           /            (month/year)
Issuing / Providing Bank :  
Country of Issuing Bank :  
Passport No :  
Billing Address :  
     
     
Amount Debit :  
Description :  
Period date of stay :  
Total nights to stay :  
 
Cardholder's Signature:
 
 
 
Signature:
 
 
 
The form has been filled out should send back to us either via fax at:
+62 361 776559 or scan and send via email in attachment therefore our company under name Bali villas for rent shall authorize debit with amount base on invoice notified.