Have a copy of Bali & Beyond delivered to your home address monthly.

Full Name	:
Address	:
City	:
Country	:   Postcode:
Phone	:
E-mail	:

Payment Method by Transfer
Delivery fees:

Within Indonesia : Rp. 150,000/year
Asia, Australia & Africa : US$ 220/year
Europe & America : US$ 240/year

Please settle payment to the following account:
PT. Bumi Dian Kusuma, (A/C. IDR) 434.01.00210.00.4
CIMB NIAGA - CAB. KUTA GRAHA, KUTA-BALI

Fax this form and proof of transfer to (0361) 750 075
Please reconfirm your fax by calling (0361) 886 8601-2