Villa Diana Bali Credit Card Autorization form

Please print this credit card authorization form and Fax to : +62-361-751510

Villa Diana Bali
(Diana Group Hotel)

CREDIT CARD AUTHORIZATION FORM

To secure my reservation I hereby to authorize Villa Diana Bali to charge my credit card as specified hereunder & Copy Credit Card + Copy Passport, attached. Being Charge for Accommodation, etc :
Hotel Name	: ___________________________________________
Check-In / Out	: ___________________________________________
Total amount	: ___________________________________________

Type of Card	: ___________________________________________
Card Number	: ___________________________________________
CVV (AMEX only)	: ________________ (3 or 4 last digit not embossed).
Issuing Bank	: ___________________________________________
Expired Date	: ___________________________________________
Card Holder's Name	: ___________________________________________

Passport Number	: ___________________________________________
Date of Birth	: ___________________________________________
Billing Address	: ___________________________________________ ___________________________________________ ___________________________________________

I understand that credit card payment are subject to 3.5% added bank service charge and calculated on the bank exchange rates the day processing. Also the Credit Card will charge 14 days (Low Season) and 21 days (High season) prior to arrival/date of tour request. Differences in personal statement balances can occur and are due to the fluctuation with the Indonesian Rupiah (IDR) and bank processing time. We are not held responsible to these differences.
By sending this Credit Card Authorization Form I agree with Villa Diana Bali Terms & Conditions.

Card Holder's signature :

Front Copy Credit Card

Back Copy Credit Card

Copy Valid Passport Page

Villa Diana Bali
(Diana Group Hotel)
Jl. Kresna – Uluntanjung / Jl. Nakula – Legian – Bali
Phone : 62-361-7441282
Fax : 62-361-751510
Hp. : 0361-7451600
Email: info@dianagrouphotel.com | Web Site: http://www.dianagrouphotel.com