DEUTSCHE VERSION. NOCH NICHT IMPLEMENTIERT.

KIWILAND HOLIDAY Fax Booking Form
Pls. print (Alt F,P), enter detaiIs from your quote and fax to:

0064 - 9 - 479 - 13 - 62

Our Quotation number:________________

Our Total Price as quoted: $NZ_

Our Deposit (10%) as quoted: $NZ_

Our remaining sum as quoted: $NZ_______________

Please enter Payment details:

I will pay by (tick one):
_Credit Card
_Money Order
_I will mail
a Bank-Cheque Deposit (tick one):
_Credit Card
_Money Order
_I will mail
a Bank-Cheque Remaining sum (tick one):
_Credit Card
_Money Order
_I will mail
a Bank-Cheque

Credit Card (tick one):

_ AMEX _ VISA _ MASTERCARD _ DINERS

Credit Card Number: __

Name on the Credit Card:

Expiry Month on the Card:

Expiry Year on the Card:

Amex Security Number:

Please enter Your personal details:

Your Email Address: _
Pls. make sure you get it right.
We can't contact you otherwise.

Pls. Confirm Your Email:

Your Name:
Your Tel: (includ. area code)
Your Fax: (includ. area code)

Your Address (incl. country):
_________________

Your postal address if different from above:
_

Names of all other people
included in this booking:
_

Any other comments or remarks:

____________________________

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Kiwiland Ltd.
P.O. Box 35941
Browns Bay
Auckland

New Zealand
Email:kiwiland@kiwiland.co.nz
Website: www.kiwiland.co.nz
Fax: 0064 9 479 13 62

I accept the quote for my vacation and/or travel in New Zealand and make and confirm a fixed reservation for myself and all persons listed. I herewith authorise KIWILAND to debit my credit card for the services booked unless I pay by Bank cheque.