CREDIT CARD DETAILS BY FAX FORM
To : VILLAS-LOMBOK.COM
Facsimile No. : +62 361 725744
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 |
: |
|
| |
|
|
| |
|
|
I am sending you a copy of my credit
card (front & back) and a copy of my passport, if you
have not received my reservation request yet, please contact
me on:
| Telephone No. |
: |
|
| Facsimile No. |
: |
|
| Email
Address |
: |
|
|