I, _________________________________________ herewith inform my credit card details to

guarantee my reservation at

Name of Villa or Hotel: _____________________________

Date of Arrival: _____________________________

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: _________________________________

Cardholders Name: __________________________________

Expiry Date: _____________________________

Name of issuing Bank: ____________________________

Billing address : __________________________________________

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

Cardholders Signature: ___________________

Date: ______________________

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