Thank you, we have received your requested form.
Please fill in the form below as the way you chosen to send your credit card details to us
to complete your reservation procedure. Firstly, click the bottom "print this form!" below and fill in the form completely including the copy of your credit card and passport. Secondly, send it by facsimile.
IMPORTANT : Your reservation will NOT be proceeded until we receive your credit card details.
Thank you very much for your great corporation.

CREDIT CARD AUTHORIZATION FORM

I hereby authorize A&T Holidays to charge my credit card as specified here under according to your TERMS AND CONDITIONS in order to pay room accommodation at _____________________ for ____ night(s). Arriving on ________________ and departing on _______________

Card Holder's Name	: __________________________________
Type of Card	: __________________________________
Card Number	: __________________________________
CVV	: _________ (4 or 3 last digit numbers which not embossed).
Issuing Bank	: __________________________________
Expired Date	: __________________________________
Passport Number	: __________________________________
Date of Birth	: __________________________________
Billing Address	: __________________________________   __________________________________   __________________________________
Total Amount	: __________________________________

I consent to pay the transaction in INDONESIA RUPIAH according to the exchange rate at the time of billing, which will be charged 14 days prior to the date of my arrival on a low season and 30 days on a peak season. Card Holder's signature :

Please find below the front and back copy of my credit card :

Front Copy

 

 

 

 

 

 

 

 

 

 

 

 

Back Copy

 

 

 

 

 

 

 

 

 

 

 

 

 

My copy valid passport

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________________________________

For further information please contact : A&T HOLIDAYS TOURS AND TRAVEL Head Office: Jl. Gelatik 7D, Cakranegara 83231 Lombok - Indonesia Phone: +62 370 640107 - 108 (hunting) Fax: +62 370 634533 Email : lomboksales@lombokandbeyond.com Bali Branch Office : Phone.: +62 361 265002 Fax.: +62 361 265002 Email : balisales@lombokandbeyond.com Contact Person : Mr. Sidyq Mobile Phone : +62818550884

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