Alternativly fill in the form, sign it, then scan and email to info@balivillasvacation.com

Name of Villa :                                                                          Bali - Indonesia.

Check in date:            /        /         Flight Number                     Arrives           :         hrs.

Check out date:         /        /          Flight Number                     Departs          :         hrs.

Total number:  Adults:          Children:         Total number of nights required:                   

Rental Fee: US$              per night.  Minimum Deposit 50% US$                Balance US$                   

If you have any special requests such as a meal upon arrival, a list of groceries you need (including wines or beers) or to reserve tours or activities then please include these on a separate fax or e-mail.

I/we hereby apply for the aforementioned Villa on the dates specified above and I/we authorize payments to be charged to the credit card specified hereunder in accordance with CV. Kery terms and conditions as payment for accommodation on Bali. Click here to read our Terms & Conditions.

Signed:                                                                                                                                        

Print Name:                                             e-mail address:                                                            

Telephone: Home                                                  Work/Mobile:                                                 

Credit Card Payment in favor of CV. Kery - I hereby authorize the payment of US$                   be converted to Rp. CV. Kery Use Only (Indonesian Rupiah), and charged to my credit card as payment for the aforementioned accommodation in Bali.

Card Type: Visa* / MasterCard* (*Delete as applicable)

Card Number:                                                                                                                                  

Expiry date:                                                Approval Code (for bank use only):                              

Last 3 digits in signature section on back of card (if any):                                                               

MasterCard ICA Number or Visa 4 digits:                                       (MC - back of card, usually bottom right corner - Visa 4 digits on front below CC No.)

Name of issuing bank:                                                                                                                   

Cardholders Name:                                                                         Date of Birth:                          

Cardholders Signature:                                                                                                                 

Passport number:                             Expiry date:                          Nationality:                              

Billing Address (where the CC statements go to)                                                                           

                                                                                                                                                      

Thank you for booking with CV. Kery. Remember to fax the completed form to +62-361-257 134 Once your credit card has been approved your confirmation voucher will be issued.