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Copyright ©
www.balihilton.com
Official website of
Bali Hilton International


REQUISITION FORM

Personal Information
Salution:
*First Name:
*Last Name:
*E-mail:
*Phone:
Fax:
Address:
City:
State:
Zip Code:
Country:
Sex:
Date of Birth:
Nationality:
Company:
*) Required
   
Flight Information
Arrival at Bali  
Flight Number:
Arrival Date:
Arrival Time:
Airport Pickup required:
(extra charge at US$ 5++ per person) 		Yes No
   
Departure From Bali  
Flight Number:
Departure Date:
Departure Time:
   
Reservation Information
Check-In Date:
Check-Out Date:
Room Choice:
Number of Room(s):
Extra Bed Required: Yes No
Number of Extra Bed(s):
Number of Person(s):
Note:
   
Credit Card Information
Card Type:
Name on the Card:
Card Number: - - -
Expiration Date:

IMPORTANT: PLEASE NOTE THAT BY CLICKING THE "Send Request" BUTTON BELOW TO
SUBMIT YOUR RESERVATION REQUEST TO US, YOU AGREE WITH & ACCEPT THE TERMS AND CONDITIONS.