I, _________________________________________ herewith inform my credit card details to guarantee my

reservation at  BALI TRIP TRANSPORT SERVICE & CAR RENTAL

Type of Car: _____________________________

Pickup Date: _____________________________

Drop-off Date: _____________________________

If cancellation is occur as stated in Terms & Conditions, I authorize Kunang Kunang Paradise Bali

to charge my credit card as [   ] a Cancellation Fee, [   ] Full Payment  as  rental charge

in amount US$ __________________

Credit Card Type: ___________________________________

Credit Card Number: _________________________________

Cardholder Name: ___________________________________

Expiry Date: _____________________________

Cardholder's Signature: ___________________


Issue bank: ______________________________


Billing address: __________________________________


The Card Identification Number (Card ID)
last three number at the back of card : __________________________
 

Date: ______________________

FRONT COPY

BACK COPY