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Credit Card Authorization Form: Note

This document is a credit card authorization form for a guest staying at Grand Lagoi Village. It requests the guest's contact information, arrival and departure dates, villa details, credit card information including card number and expiration date, and authorizes Grand Lagoi Village to charge the total reservation amount to the provided credit card. The form notes that payment will be converted to Indonesian Rupiah at the time of payment using the exchange rate of a reputable commercial bank. The guest must sign and provide a copy of their credit card and ID.

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Propan Hanggada Satyamakti M
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223 views1 page

Credit Card Authorization Form: Note

This document is a credit card authorization form for a guest staying at Grand Lagoi Village. It requests the guest's contact information, arrival and departure dates, villa details, credit card information including card number and expiration date, and authorizes Grand Lagoi Village to charge the total reservation amount to the provided credit card. The form notes that payment will be converted to Indonesian Rupiah at the time of payment using the exchange rate of a reputable commercial bank. The guest must sign and provide a copy of their credit card and ID.

Uploaded by

Propan Hanggada Satyamakti M
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CREDIT CARD AUTHORIZATION FORM

Name : ____________________________
Contact No. : ____________________________
Fax No. : ____________________________
Email Address : ____________________________

Arrival Date : ____________________________


Departure Date : ____________________________

Guest Name : ____________________________

Villa Type : ____________________________

Other Services : ____________________________

Type of Credit Card : ( ) AMEX ( ) VISA ( ) MASTER ( ) JCB ( ) UNION PAY

Credit Card Number : ____________________________ Exp. Date : _______


Amex Identification Number (4 or 3 digit) : __________
Visa/Master/JCB Identification Number (4 or 3 digit) : __________
Union Pay Identification Number (4 or 3 digit) : __________

Note :
In accordance with the banking regulations of the Republic of Indonesia, payment by credit card shall be
denominated in Rupiah.
The conversion to Rupiah shall be made at the time of payment at the selling rate advised by a reputable
commercial bank

Please authorize at space below and enclose a clear Credit Card copy of both sides and ID Card/Passport copy.

I authorize Grand Lagoi Village to charge the total amount of IDR __________ to my Credit Card for the
reservation booking as mentioned above.

Card Holder Details

Signature : ____________________________
(as it appears on the Credit Card)
Card Holder Name : ____________________________
Date : ____________________________
Address : ____________________________

Jalan Gurindam Dua Belas Plot 27-29


Sebong Lagoi, Pulau Bintan 29155, Kepulauan Kepri, Indonensia
Phone (62-770) 692988 Fax (62-770) 692980
www.grandlagoi.com

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