TitleMr.Miss.Mrs. Full Name GenderFemaleMale Nationality United StatesCanadaMexicoUnited Kingdom-----AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Email Cell Phone Number Afghanistan +93Albania +355Algeria +213American Samoa +1-684Andorra +376Angola +244Anguilla +1-264Antarctica +672Antigua +1-268Argentina +54Armenia +374Aruba +297Ascension +247Australia +61Australian External Territories +672Austria +43Azerbaijan +994Bahamas +1-242Bahrain +973Bangladesh +880Barbados +1 -246Barbuda +1-268Belarus +375Belgium +32Belize +501Benin +229Bermuda +1-441Bhutan +975Bolivia +591Bosnia & Herzegovina +387Botswana +267Brazil +55British Virgin Islands +1-284Brunei Darussalam +673Bulgaria +359Burkina Faso +226Burundi +257Cambodia +855Cameroon + 237Canada +1Cape Verde Islands +238Cayman Islands +1 -345Central African Republic +236Chad +235Chatham Island (New Zealand) +64Chile +56China (PRC) +86Christmas Island +61-8Cocos-Keeling Islands +61Colombia +57Comoros +269Congo +242Congo, Dem. Rep. of (former Zaire) +243Cook Islands +682Costa Rica +506Côte d'Ivoire (Ivory Coast) +225Croatia +385Cuba +53Cuba (Guantanamo Bay) +5399Curaçao +599Cyprus +357Czech Republic +420Denmark +45Diego Garcia +246Djibouti +253Dominica +1-767Dominican Republic +1-809 and +1-829East Timor +670Easter Island +56Ecuador +593Egypt +20El Salvador +503Ellipso (Mobile Satellite service) +8812, +8813EMSAT (Mobile Satellite service) +88213Equatorial Guinea +240Eritrea +291Estonia +372Ethiopia +251Falkland Islands (Malvinas) +500Faroe Islands +298Fiji Islands +679Finland +358France +33French Antilles +596French Guiana +594French Polynesia +689Gabonese Republic +241Gambia +220Georgia +995Germany +49Ghana +233Gibraltar +350Global Mobile Satellite System (GMSS) +881ICO Global 8810,8811Ellipso 8812, 8813Iridium 8816, 8817Globalstar 8818, 8819Globalstar (Mobile Satellite Service) +8818, +8819Greece +30Greenland +299Grenada +1-473Guadeloupe +590Guam +1-671Guantanamo Bay +5399Guatemala +502Guinea-Bissau +245Guinea +224Guyana +592Haiti +509Honduras +504Hong Kong +852Hungary +36ICO Global (Mobile Satellite Service) +8810, +8811Iceland +354India +91Indonesia +62Inmarsat (Atlantic Ocean - East) +871Inmarsat (Atlantic Ocean - West) +874Inmarsat (Indian Ocean) +873Inmarsat (Pacific Ocean) +872Inmarsat SNACNote: Inmarsat plans to shift all other codes to this Single Network Access Code by 2009. +870International Freephone Service +800International Shared Cost Service (ISCS) +808Iran +98Iraq +964Ireland +353Iridium (Mobile Satellite service) +8816, +8817Israel +972Italy +39Jamaica +1-876Japan +81Jordan +962Kazakhstan +7Kenya +254Kiribati +686Korea (North) +850Korea (South) +82Kuwait +965Kyrgyz Republic +996Laos +856Latvia +371Lebanon +961Lesotho +266Liberia +231Libya +218Liechtenstein +423Lithuania +370Luxembourg +352Macao +853Macedonia (Former Yugoslav Rep of.) +389Madagascar +261Malawi +265Malaysia +60Maldives +960Mali Republic +223Malta +356Marshall Islands +692Martinique +596Mauritania +222Mauritius +230Mayotte Island +269Mexico +52Micronesia, (Federal States of) +691Midway Island +1-808Moldova +373Monaco +377Mongolia +976Montenegro +382Montserrat +1-664Morocco +212Mozambique +258Myanmar +95Namibia +264Nauru +674Nepal +977Netherlands +31Netherlands Antilles +599Nevis +1-869New Caledonia +687New Zealand +64Nicaragua +505Niger +227Nigeria +234Niue +683Norfolk Island +672Northern Marianas Islands (Saipan, Rota, & Tinian) +1-670Norway +47Oman +968Pakistan +92Palau +680Palestinian Settlements +970Panama +507Papua New Guinea +675Paraguay +595Peru +51Philippines +63Poland +48Portugal +351Puerto Rico +1-787 or +1-939Qatar +974Réunion Island +262Romania +40Russia +7Rwandese Republic +250St. Helena +290St. Kitts/Nevis +1-869St. Lucia +1-758St. Pierre & Miquelon +508St. Vincent & Grenadines +1-784Samoa +685San Marino +378São Tomé and Principe +239Saudi Arabia +966Senegal +221Serbia +381Seychelles Republic +248Sierra Leone +232Singapore +65Slovak Republic +421Slovenia +386Solomon Islands +677Somali Democratic Republic +252South Africa +27Spain +34Sri Lanka +94Sudan +249Suriname +597Swaziland +268Sweden +46Switzerland +41Syria +963Taiwan +886Tajikistan +992Tanzania +255Thailand +66Thuraya (Mobile Satellite service) +88216Timor Leste +670Togolese Republic +228Tokelau +690Tonga Islands +676Trinidad & Tobago +1-868Tunisia +216Turkey +90Turkmenistan +993Turks and Caicos Islands +1-649Tuvalu +688Uganda +256Ukraine +380United Arab Emirates +971United Kingdom +44United States of America +1US Virgin Islands +1-340Universal Personal Telecommunications (UPT) +878Uruguay +598Uzbekistan +998Vanuatu +678Vatican City +39, +379Venezuela +58Vietnam +84Wake Island +808Wallis and Futuna Islands +681Yemen +967Zambia +260Zanzibar +255Zimbabwe +263 IdentityeKTPPassport Number of Identity Date of Treatment Time of Treatment 08.0009.0010.0011.0012.0013.0014.0015.0016.0017.0018.0019.0020.0021.00 Total Pax123456 Appointment & Cancellation Making your appointment prior to arriving at Spa Village is strongly recommended. Reservations are subject to availability and must be guaranteed with a credit card, PayPal or transfer to our bank account, so please select below payment method before submit the reservation form. Be sure to mention any special or medical issues needs when booking your appointment, and please avoid the body wrap treatments and beer spa if you have high blood pressure or are pregnant. Please note that once an appointment is booked, unless we hear otherwise, we’ll be expecting you. Since treatment and package times are reserved especially for you, cancellations must be 24 hours prior to your scheduled appointment to avoid being charged in full for the missed or skipped appointment. How did you hear about us? Google searchFacebookInstagramInternetAdsFriends or FamilyOther Payment Type? Credit Card Name on Card Card Number Expiry Date Security Code Spa Menu Body Massage Balinese Massage 60’ – Rp. 230,000 Balinese Massage 90’ – Rp. 280,000 Aromatherapy Massage 60’ – Rp. 250,000 Aromatherapy Massage 90’ Rp. 300,000 Village Massage 90’ – Rp. 280,000 Village Massage 120’ – Rp. 350,000 Village Herbal Massage 90’ – Rp. 280,000 Village Herbal Massage 120’ – Rp. 400,000 Village Hot Stone 90’ – Rp. 280,000 Village Hot Stone 120’ – Rp. 400,000 Back & Head Massage 30’ – Rp. 95,000 Back & Head Massage 60’ – Rp. 190,000 Body Care Javanese Scrub 30’ – Rp. 220,000 Coffee Scrub 30” – Rp. 200,000 Fruit Scrub 30’ – Rp. 200,000 Lavender Salt Scrub 30’ – Rp. 180,000 Village Milk Bath 30’ – Rp. 100,000 Javanese Wrap 60’ – Rp. 250,000 Dead Sea Clay Wrap 60’ – Rp. 280,000 Reflexology Reflexology Massage 60’ – Rp. 130,000 Reflexology Massage 90’ – Rp. 160,000 Face Care Collagen Eye Treatment 30’ – Rp. 80,000 Ear Candling 30’ – Rp. 80,000 Signature Facial 75’ – Rp. 220,000 SPA PACKAGE Village Refined 120’ – Rp. 400,000 Village Indulgence 150’ – Rp. 485,000 Village extravaganza 180’ – Rp. 750,000 Essence of Spa Village 240’ – Rp. 880,000 BEER SPA Beer Spa Signature 120’ – Rp. 600,000 Beer Spa Full Body Massage 90’ – Rp. 420,000 Beer Spa Back & Head Massage 60’ – Rp. 300,000 Beer Spa Body Bath 30’ – Rp. 250,000 Promotions WEEKDAYS BEER SPA DAYS – Rp. 480,000 2D1N WEEKDAYS STAY & SPA PACKAGE’ – Rp. 525,000 BEER SPA & STAY’ – Rp. 787,000