poltalock station

near the Coorong, South Australia

CREDIT CARD PAYMENT FORM

This is a Secure Order Form.

Please complete the form below and enter your credit card information in the
secure pop up window that appears when you click the button provided.

We take the security of your information extremely seriously, and have chosen
to use the Mals-E system, which securely stores your details off-site from
our premises and does not transmit any information via email.

A deposit of $100 of the total accommodation cost is required to confirm
your booking and the remainder is due 14 days prior to your arrival.

If the booking is made less than 14 days before arrival, payment in full is required.

Your Name:
Postal Address:
City:
State:
Postcode:
Country:
Telephone:
Email:
Amount of payment:	$
		Please charge the balance of my payment to my credit card 14 days prior to arrival, unless I notify you otherwise.
Comments or Questions:

Poltalloch Station
PMB 3, Narrung via Tailem Bend
South Australia 5260
Phone: +61 (0)8 85740043
Fax: +61 (0)8 85740065
Email: info@poltalloch.com.au