Name of Hotel or Resort:
Arrival Date:
Check-In Date:
Check-Out 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, charged at first one night accommodation

In Amount US$:
Credit Card Type:
Credit Card Number:
Cardholder's Name:
Expiry Date:
Name of Issuing Bank:
Cardholder's Signature:
Date:

Front and Back copy of the credit card is required

ONCE FORM IS COMPLETED, KINDLY FAX TO +62 361 974 923

Jalan Raya Sayan, Ubud, Bali - INDONESIA
Tel. / Fax. +62 361 974923 Mobile Phone +62 (0) 812 395 2032
E-mail: bbainfo@bali-thepages.com