VisionBali online reservation

To: (PT. Visionbali)
Co: Nyoman D. Sridana

I, ________________________have sent you a room reservation (as on our corresponds) for hotel_________________________, staying from date __ __ / __ __/ 200__ to date __ __ / __ / 200__ ( __ night(s)) with type of the room ___________ room through visionBali online reservation, via the Internet / email, without my credit card details on the form, as on our agreement with the total amount of US$ _______ or in local curency (Rupiah) amount of Rp_______________.

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 room(s) I have asked you to reserve for me. I have read and accept your Terms & Conditions as detailed as on VisionBali Hotels & Accommodation's "Terms & Conditions" web-site page;

Type of Card :__________________________________
Issuing Bank :__________________________________
Card Number :__________________________________
Expiry Date :__________________________________
Cardholder's Name :__________________________________
Date of birth :__________________________________
Passport No. :__________________________________
The number writen on the back cover
(3 digit number)
Your complete Address


Cardholder's Signature





we can meet you for hotel transfer or payments in ________________________( name of hotel& hotel's phn No. or in Denpasar Airport when arriving by _____________ airline with flight No.______________________ & time of arriving at ____________)

Also we need the copy of your both side credit card, please send the copy by fax when you send this form to fax No 62 361 243486

If you can not received payments from our credit card through your Bank yet and / or need me to send you a copy of my passport, please contact me on Fax No._______________or Phone No. ______________


AND inform VisionBali online by email at, please send to Fax No.: xx 62 361 243486