CREDIT CARD AUTHORIZATION
Service require:
______________________________________________________________
(e.g.
Na
me
of the Hotel or Tour Program , lengh of stay, )
Guest Name: ________________________________________________________________
Address: ___________________________________________________________________
City: __________________________________
ZIP Code: ___________________________
State / Region:
___________________________ Country: ____________________________
Telephone Number:
______________________ Fax Number: __________________________
This letter authorizes
Bali Holiday Travel Service to charge the
following amount
on my credit card for the service / guest listed above.
Total Charge: _______________ US $
equal to: ________________________ Indonesian Rp
Type of Credit Card:
O Master Card O Visa
Card O Amex
Issuing Bank :
_______________________________________________________________
Credit Card Number:
__________________________________________________________
Expired Date: _______________________
(Month / Year)
Name as it appears on Credit Card:
_______________________________________________
Date, Cardholders Signature:
____________ , _______________________________________
Please
forward also a copy of a valid passport of the cardholder and a copy of
the front and back side of the credit card
via facsimile
to: Fax : +62 - 361 -
461131
Bali
Holiday /
Griyasar Tours & Travel
GRIYASARI TOURS & TRAVEL
Address : Jl. Gatot Subroto No. 49
Kesiman - Kertelangu
Denpasar
Bali - Indonesia
Phone :+ 62 - 361 - 461910
Phone : +62 - 361 - 467459
Fax : +62 - 361 - 461131
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