Thank you, we have received your requested form. Please fill in the form below to send your credit card details to us to complete your reservation procedure. First, click the bottom "print this form!" below and fill in the form completely including the copy of your credit card and passport. Second, send it by facsimile. IMPORTANT : This credit card details are only for a guarantee. IT IS NOT DEPOSIT NOR PAYMENT. Payment is to be made directly to the hotel when you check in either by cash or credit card CREDIT CARD FORM I hereby authorize _____________________ approved by BaliBagus.com to use my credit card as specified here under according to your TERMS AND CONDITIONS in order to guarantee room accommodation at _____________________ for ____ night(s). Arriving on ________________ and departing on _______________ Card Holder's Name : __________________________________ Type of Card : __________________________________ Card Number : __________________________________ Issuing Bank : __________________________________ Expiry Date : __________________________________ Card Holder's signature :   For further information please contact : BaliBagus.com Bali Hotel and Villa Reservations Jalan Tukad Pancoran 16, Denpasar - Bali, Indonesia Phone/Fax: +62 (361) 245505 Print this form!

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