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BALI HOTELS - RESERVATION FORM
PLEASE FILL OUT THE FORM WITH VALID INFORMATION
PERSONAL INFORMATIONS
Title
:
Mr.
Mrs.
Miss
Ms.
Others
First Name
:
Last Name
:
Address (line 1)
:
Address (line 2)
:
City / State
:
Country
:
Telephone
:
-
-
Fax
:
-
-
Email Address
:
ACCOMMODATION INFORMATIONS
Hotel Name
:
--- Select Hotel ---
Puri Nusantara Hotel
Room Type
:
--- Select Room ---
1 Bed Room
2 Bed Rooms
3 Bed Rooms
Family Room
Standard
Superior
Deluxe
Suite
Presidential
Extra Bed
:
No Extra Bed
1 Extra Bed
2 Extra Beds
3 Extra Beds
Check-In Date
:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
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9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
Year
2008
2009
Check-Out Date
:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
Year
2008
2009
No of PAX
:
Person(s)
Adults
:
Person(s)
Children
:
Person(s)
TRANSPORTATION INFORMATIONS
Transport From / To Airport?
No
Yes
Arrival Date
:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
Year
2008
2009
Arrival Time
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
:
Minute
00
05
10
15
20
25
30
35
40
45
50
55
Arrival Flight No.
:
Departure Date
:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
Year
2008
2009
Departure Time
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
:
Minute
00
05
10
15
20
25
30
35
40
45
50
55
Departure Flight No.
:
PAYMENT & OTHER INFORMATIONS
Payment Method
:
Credit Card
Bank Transfer
Credit Card Type
:
VISA Card
MASTER Card
Question, Commend or Request
:
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