EmailMe Form - Cloud 9 Getaways Credit Card Authorization Form

I, (full name) authorize Cloud 9 Getaways to charge my credit card *

on or after (date for charge) *

MM / DD / YYYY

for the amount of: *

$ Dollars . Cents

This payment is for *

Enter a brief description of trip.
Include a booking number if you have one.

*

Deposit

Additional Payment

Final Payment

Travel Insurance

Card Type: *

Visa

MasterCard

American Express

Discover

Credit Card Number: *

Expiration Date: *

As it appears on card

Security Number: *

VISA, MASTERCARD, DINERS & DISCOVER credit cards have a three-digit number. It is printed in the
signature panel on the back of the Visa, MasterCard and Discover cards. The verification number is the last 3 digits
on the right side of the panel. AMERICAN EXPRESS credit cards have a 4 digit non-embossed number. It is printed
above the account number on the front of your card

Full Name, as it appears on credit card: *

Prefix First Middle Last Suffix

Billing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone Number: *

### - ### - ####

Digital Signature:

I hereby authorize Cloud 9 Getaways to charge the indicated credit card listed above for the travel
services stated above. I guarantee and warrant that I am the legal cardholder for this credit card. *

First Last

Today's Date: *

MM / DD / YYYY

Please Auto-charge my card 1 week before my final payment due date. Cloud 9 Getaways will send you an email reminder 1 week before processing the final payment. *

Yes

No

Email Address *