To inquire about the availability of a room or to place a final order fill out the form below. Almost all fields are required and only the additional comment is optional.

Our [Privacy Statement] explains how we handle the data you are providing.

Personal Information
First Name
Last Name
Sex	Male Female
Email Address

Address Information (Home)
Street Address
City
Zip
State
Phone Number
Country	** please select ** Argentina Aruba Australia Austria Bahamas Bangladesh Barbados Belgium Belize Benin Bermuda Bolivia Bouvet Island Brazil Brunei Darussalam Canada Cape Verde Cayman Islands Chile China Christmas Island Colombia Cook Islands Costa Rica Croatia (Hrvatska) Cyprus Czech Republic Denmark Dominica Dominican Republic East Timor Ecuador Egypt Estonia Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Germany Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Kazakhstan Korea, Republic of Kuwait Latvia Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Malaysia Marshall Islands Martinique Mexico Monaco Morocco Mozambique Namibia Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Russian Federation Rwanda Saint Lucia Saint Vincent Saudi Arabia Singapore Slovenia Solomon Islands South Africa Spain Sri Lanka St. Helena Sudan Sweden Switzerland Taiwan Thailand Trinidad and Tobago Tunisia Turkey Uganda United Arab Emirates United Kingdom United States Uruguay US Minor Outlying Islands Vatican City Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Yemen

Check In Information
Check In	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 January February March April May June July August September October November December 2016 2017 2018
# Nights	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
# Guests	1 2 3 4 5 6 7 8 9 10 11 12 Adults 1 2 3 4 5 6 7 8 9 10 11 12 Children (< 12)
Extra Bed	1 2 3 4 5 6 7 8 9 10 11 12 (1 Rollaway Bed, 1 Person)
Bed Request	(Based On Availability)
Breakfast Required?	Yes No

Airport Transfer
Arrival Transfer	Not required! Yes, please arrange airport to hotel transfer!
Arrival Flight #	(leave blank if not required!)
Arrival Time	(HH:MM)
Departure Transfer	Not required! Yes, please arrange hotel to airport transfer!
Departure Flight #	(leave blank if not required!)
Departure Time	(HH:MM)

Additional Information
Comments

Newsletter Subscription
Bali Update	Yes, subscribe my email address to the Bali Update, our FREE weekly newsletter with lots of information from the Island of the Gods!

Please enter the code as shown above duplicating the Capital and small case of the any letters exactly as shown.