Thank you, we have received your requested form.
Please fill in the form below as the way you chosen to send your credit card details to us
to complete your reservation procedure. Firstly, copy this form to your local disk and edit it using
any program you're familiar with such as Microsoft Word. Secondly, fill in the form completely
including the copy of your credit card and passport. Thirdly, send it by facsimile.
IMPORTANT : Your reservation will NOT be proceeded until we receive your credit card details.
Thank you very much for your great corporation.

CREDIT CARD AUTHORIZATION FORM

 

    I hereby authorize ACCESS BALI ONLINE (ABWD) to charge my credit card as

    specified hereunder according to your  TERMS AND CONDITIONS   in  order  to

    pay an advertising fee for  _____________________ at ABWD pages that will

    start on  _______________ and end on __________________.
Card Holder's Name : __________________________________
Type of Card : __________________________________
Card Number : __________________________________
CVV : _________ ( 4 or 3 last digit numbers which not embossed).
Issuing Bank : __________________________________
Expired Date : __________________________________
Passport Number : __________________________________
Date of Birth : __________________________________
Billing Address

 : __________________________________
  __________________________________
  __________________________________
Total Amount : __________________________________


    I consent to pay the transaction in INDONESIA RUPIAH according to the

    exchange rate at the time of billing, which will be charged 14 days prior

    to the date of my arrival on a low season and 30 days on a peak season.

    Card Holder's signature :

     

     

 

Please find below the front and back copy of my credit card :

 

                                       Front Copy                                                                Back Copy
 

 


 
 
 
 
 
 
  My copy valid passport
 
 

  

 

 

 

 

 

 

ACCESS BALI WEB DIRECTORY
Jalan Gunung Soputan, Perumahan Puri Taman Umadui Blok B-21, Denpasar, Bali, Indonesia
Email : ablsales@baliwww.com Website : http://baliwww.net
Phone : (62-361) 731520  Fax : (62-361) 734379  or  755161