To                         : THEVILLABALI.COM
Facsimile No.     : +62 361 485347


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	: .........................................................................