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Initial Payment • Cardholder Authorization Form
Vacation Dates & Destination
Primary Name on Reservation
*
First
Middle
Last
Phone
*
###
-
###
-
####
Email
*
Amount of Payment to Authorize
*
$
Dollars
.
Cents
Payment Type
*
Full Payment
Initial Deposit
Insurance
Payment (Deposit Previously Paid)
Excursions, Tours, Transfers , & Tickets
Cardholder Name
*
First
MI
Last
Billing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Credit Card Type
*
Visa
Mastercard
American Express
Discover
Credit Card Number
*
Expiration Date
*
MM
/
YYYY
CVV Number
*
3 or 4 Digit Code on Back of Card
Travel Insurance
*
Accept Insurance (or previously purchased insurance)
Waive Insurance
I acknowledge that I received travel insurance information, and that I have been informed of the cancellation policies for our travel services and have been made aware of the benefits of travel protection.
Payment Authorization Terms & Conditions:
As Primary Traveler On Reservation and on behalf of all guests on reservation: I understand this is a disclosure of business practices and permissive credit/debit card payment agreement for the purchase of travel services. I agree that payments may be made direct to selected travel suppliers on my behalf by Dana Lewis of Discovereighng with Dana Travel; paid in prorated amounts not to exceed the sum total of approved charges. I understand that some banks & credit card companies often impose “Daily Transaction Limits” and multiple payments may be needed to complete the full balance due; for which you will be notified if the situation occurs (OR you can notify your bank ahead of time to prevent booking delays).
FEES: I am aware there are potential Cancellation, Refund and Surcharge Policies and Fees by suppliers; I understand that deposits and in some cases full payments are nonrefundable without travel insurance; I understand it is my responsibility to read and abide by the policies, terms and conditions as posted on supplier documents and agree not to dispute or chargeback any of the above signed for and acknowledged charges without proper course of action.
Dana Lewis/Discovereighng with Dana Travel will not release personal information to ANY parties not listed below, unless provided in writing as an Emergency Contact and will apply due diligence in maintaining records in a secured, safe location.
Signature
*
Clear
Use your mouse or finger (on a touch screen) to sign.
Today's Date
*
MM
/
DD
/
YYYY
Notes:
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