EmailMe Form - Travel Dreams Credit Card Authorization Form

EmailMeForm

Primary Traveler's Name (or Name of Group) *
Reservation/Booking Reference # (found on your quote/confirmation - if you cannot locate you may leave this field blank)
Destination
Please choose the Travel Dreams Team agent you are working with for this reservation: *
Departure Date *
MM / DD / YYYY
Card Holder's Name *
First Middle Last Suffix
**Exactly as it appears on the cred card**
Please Provide the Credit Card Billing Address *Required* *

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

Please include Zip Code (Address Line 2: Suite, Apartment #, etc. if applicable)
Phone *
### - ### - ####
Credit Card *

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Email *
Payment Amount *
$ Dollars . Cents
Authorization
I acknowledge that I have reviewed the travel arrangements prepared for me and agree to the terms. By signing this authorization, I hereby authorize Travel Dreams to charge the credit card listed above for the travel services normally handled by travel agencies to the appropriate suppliersl. I guarantee and warrant that I am the legal cardholder for this credit card.

I/We understand that Travel Dreams is acting only in the capacity of an agent for the various suppliers of travel services listed on my travel documents and itinerary. Travel Dreams is not liable for any personal injury, property damage, or other loss, accident, delay, or inconvenience caused by any supplier or any party not under its control. Your acceptance of travel documents indicates your understanding and agreement to this.
Today's Date *
MM / DD / YYYY
Please check the appropriate box below regarding whether or not you are interested in purchasing travel protection *Please Check Only One Box* : *
I/We ARE interested in purchasing travel protection and would like to receive information & quotes.
I/We WILL NOT BE purchasing travel protection and understand that if I/We choose not to accept insurance coverage, penalties and non-refundable charges may apply.
Card Holder's Signature - SIGNATURE REQUIRED (use finger, cursor, etc to sign electronic form) *
Clear
I have read the above and agree to terms of this authorization and the decision to accept/decline travel insurance *
Clear