PAYMENT FORM

CREDIT CARD INFORMATION FAX FORM
This form is provided by Komodotours.com (an internet marketing development of Cita Travel Service Ltd - Bali).

Komodotours.com
Cita Travel Service Ltd
Jl. Bypass I Gusti Ngurah Rai No 280 B,
Sanur - Denpasar
Bali - Indonesia		 Phone : +62 361 466558 / 465316
Phone : +6281338994444

Fax : +62 361 465316
Please print this form, fill it out with all required information then FAX them to us after receiving our confirmation of rooms, transfers, airlines ticket, package arrangement, local excursions, meals, etc......to our office in Bali : ++62 361 465316. Any transaction using credit card will add 3% from the total bill for the local bank administration fees.
 

Hotel Name :________________________________________
City : __________________

Package Arrangement :_________________________________
Total Nights/Package Duration _______________

Guest's Name : _______________________________________
Total Person :____________

Type of room/Package ________________________________
Extra Charge : ___________

Your Arrival Date : Day_____/Date____/Month____/Year____
Arrival Flight_____________

Your Departure Date : Day____/Date____/Month____/Year____
Departure Flight__________

 
   

Cardholder's name : __________________________________________________________
(As it appears on the card)

Card Number : ______________________________________
Three small number state at the back of your card: ___________
Expire Date _____________
(VISA) MASTER CARD    
           


I hereby authorize Komodotours.com (Cita Travel Service) to charge my credit card at a total amount of _________ US$
(__________________________________________________
__________________________________________________)

 Passport Number :______________
We may need copy of your passport!
Cardholder's address : ________________________________
__________________________________________________

 Passport issued date:
______________________
Passport Expire date:
______________________
City
__________________		 State/Province
__________________		 Country
_____________		  
 

Email Address : _____________________________________________________________

Phone : (country code______) (area code_______) (phone number________________)

Phone : (country code______) (area code_______) (phone number________________)
 

 

Signature : ____________________________________
As it appears on the card

 Signed date :

_____________________
       
 

Together with this form, please kindly fax us copy of your credit card front and back side, and copy of your passport. Your transaction will only process if we receive your document in complete.
 

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