EmailMe Form - PAYMENT AUTHORIZATION

PAYMENT AUTHORIZATION

Vacation Escapes Travel by Jackie
(612)524-8747
www.vacation-escapes.com

I understand this is a disclosure of business practices and permissive payment agreement for the purchase of travel services. I authorize Travel Escapes by Jackie/Buen Viaje Travel to make payments directly to selected travel suppliers on my behalf; paid in prorated amounts not to exceed the sum total of approved charges. I understand Debit Cards often impose “Daily Charge Limits” and multiple payments may be needed to complete the full balance due. Vacation Escapes by Jackie/Buen Viaje Travel agrees not to release personal information to ANY parties not listed on your finalized Travel Contract and will apply due diligence in maintaining records in a secured, safe location.

Today's Date *
MM / YYYY
Reason for today's charge: *
Primary Traveler's Name *
First Last
I am submitting payment, to be applied to the account of the above Primary Traveler, whom is able to dicate dates, cost and details of the applicable reservation code below.
TOTAL Package Price Quote
$ Dollars . Cents
This is the Total Package Quote, which includes anticipated payments to be prorated to various suppliers; such as airlines, hotel, cruiseline, resorts, insurance, excursions and guest services-as dictated in the Quoted Travel Package. Each identified charge will be confirmed by email on date prior to payment submission and confirmed by paid receipt. This amount subject to change with any additions/removal of travel activities.
Name (as appears on credit card) *
First Last
Cardholder's Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Cardholder's Phone Number *
### - ### - ####
Credit Card *

Card Number

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Credit Card Type: *
Amount Authorized Today *
$ Dollars . Cents
MINIMUM DEPOSIT is amount required today to initiate reservation. (The date of travel, number of paying guests and supplier terms will be factored in computing required deposit amounts.) This amount is included in Total Package Quote provided in Email. You MUST pay the balance in full prior to Final Due Date or if booking within 30-45 Days of Traveling.
Signature *
Please type your name
APPROVAL OF CHARGES *
As named Cardholder; I Authorize:Vacation-Escapes by Jackie/agent- Jackie Gutierrez to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package account for the Primary Traveler listed above.
Future Payment Authorization *
I will authorize By EMAIL, all future payments due towards Total Package Cost, to be charged to the above credit card with the same terms as disclosed. I may opt to use a different Credit Card simply by submitting a new Authorization Form.
Cancellation Policy Acknowledgement *
I am aware of any potential Cancellation, Refund and Surcharge Policies and Fees by suppliers and agree not to dispute or chargeback any of the above signed for and acknowledged charges without proper course of action.
Acceptance of Mandatory Disclosure *
As Primary Traveler; I understand I am responsible to READ the Mandatory Disclosure Email that will be generated upon submission. I ACCEPT: I have 24 hours from receipt of Disclosures to submit any dispute or cancellation due to content of email.
Email For Receipt Confirmation & Mandatory Disclosure *

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