EmailMe Form - NC MGMA Payment Form

Select Type of Payment *

Reconfirm Dates of Travel

Please enter travel dates as a 2 digit month, 2 digit day and 4 digit year. Example: 01/01/1977

Departing *

MM / DD / YYYY

Returning *

MM / DD / YYYY

If traveling with a companion or roommate please provide their name in the box below. Initial deposits are $500 per person + insurance.

Billing Information

Name *

First Last

Billing Address

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

Email Address *

Phone Number *

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

Credit Card Information

Credit Card Company *

Credit Card *

Payment Amount *

$ Dollars

Please round up to the nearest whole dollar value. Field will not accept cents.

Additional Comments?

If you would like us to keep this card on file and automatically charge your additional payments on the indicated group payment dates please indicate so here.

Signature (Use finger or mouse to sign) *

Clear

By submitting, you certify that you are the cardholder and are authorizing Dreams and Destinations, Inc. or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate and will not dispute or chargeback. You also certify you have read the Terms & Conditions and the appropriate Travel Protection Plan details. Cancellation penalties may apply. Insurance is not refundable. This charge will be manually applied by your Dreams and Destinations travel professional to your reservation and may reflect as Dreams and Destinations, or your airline or our travel supplier. If there are any issues, your agent will notify you.

Payment may take 3-5 business days to fully process and be reflected on your statement.

I authorize Dreams and Destinations, Inc to use the above information to charge my credit card the stated amount and any additional payments if I indicated on this form.

Terms and Conditions *

I Agree to the Terms