CREDIT CARD AUTHORIZATION FORM
Hotel Villa
Lalu
Jalan Pura Dalem
Seminyak, Kuta, Bali
Indonesia
Tel : 62. 361. 731051
Fax : 62. 361. 731052
Email : vilalalu@indosat.net.id
For safety reasons, we recommend that payment be made by FAX
Please follow these
instructions :
1 ) Print out this Credit Card Authorization Form
2 ) Fill in the form and then sign it
3 ) Then fax the form to Villa Lalu : Fax number : 62. 361. 731052
Credit Card
Authorization Form
Cardholder's name: ................................................................
( as stated on your credit card )
Billing address
: ......................................................................
City: .............................................. Postal code: ....................
Country : ..............................................................................
I hereby authorize
Hotel Villa Lalu to charge :
Amount : US$ ........................................................................
Amount in words : US$ ............................................................
on my credit card -- ( ) Visa ( ) MasterCard ( ) JCB
Card number : .............................................................. Expiry date : ................
as a deposit for reserved accommodation at Hotel Villa Lalu.
Signature of
cardholder : ......................................................... Date:
................
( as shown on your credit card )
=====================================================
For official use
only
Approval code :
.....................................................................
Amount in Indonesian Rupiah :
.....................................................................