abltech.com | CREDIT CARD AUTHORIZATION FORM

Please fill in the form below to complete your order.
Firstly, save this form to your local disk or print it.
Secondly, fill in the form completely.
Thirdly, send it by facsimile to (62-361) 734379 or 735145.
IMPORTANT : Your order 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 ABL Tours and Travel Ltd. to charge my credit card as

specified hereunder according to your TERMS AND CONDITIONS in order to

pay ____________________________________________________

________________________________________________________

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

I consent to pay the transaction in INDONESIA RUPIAH according to the

exchange rate at the time of billing.

Card Holder's signature :

ABL TOURS AND TRAVEL LTD.

Jalan Gunung Soputan, Perumahan Puri Taman Umadui Blok B-21
Denpasar, Bali, Indonesia

Email : abltechsales@abltech.com Website : http://abltech.com

Phone : (62-361) 731520 (Hunting) Fax : (62-361) 734379 or 735145