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

reservation at Hire Car Bali. Com

Type of Car: _____________________________

Pickup Date: _____________________________

Drop-off Date: _____________________________

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

to charge my credit card as a Cancellation Fee, charged at 50% of one day rental fee

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: ______________________

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