Credit Card Payment Statement

I take the responsibility of the payment of my clients as the following details:

Name:
Arrival:
Service required:
Cost:
Service fee: 3 %
Grand Total:
Inclusions:

Herewith I give the authorization to Lumbung Bali Tours to charge my Visa Card / MasterCard as amount US$ …….. I fully understand that the charge will be in Indonesian Rupiah according to the current exchange rate.

Card number:
Holder Name:
Expired:
Passport No:
Address:
Phone:
Fax:
Email:

Counter signature,

(…………………………)

Enclosed: the copy of both sides of my credit card