Please fill in the necessary data and fax form together with copies of passport and credit card (both sides) return to
fax no +62 (361) 257134
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| Beneficiary |
CV Kery
Address : Jalan pulau adi dalam no 17 Denpasar Bali
Phone : +62 (361) - 7870721
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| Player's Data : |
| Name : |
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| Address : |
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| City : |
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| Country : |
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| Telephone : |
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| Email : |
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| Nationality : |
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| Passport No : |
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| Amount in IDR or Rupiah : |
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| Amount (in latters) : |
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Credit Card Information : |
| Name (as writtern on the credit card) : _____________________________________________________________ |
| Card Type : |
Visa Card / MasterCard |
| Credit Card Company : |
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| Issuing Bank of Credit Card : |
__________________ City : ____________________________________________ |
| Credit Card Number : |
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| Credit Card Expire Date : |
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Month
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Year
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Security Code *
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(*) Security Code is applicable on Visa and MasterCards. It is the last 3 digit numbers on the signature panel of your vissa or mastercard back side
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| I hereby authorize CV. Kery to charge the above amount to my credit card. |
| Date : |
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| Cardholder's Name
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Signature
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