EmailMe Form - Twin Gemini's Travel Client Intake & Payment Form

EmailMeForm

Today's Date *
MM / DD / YYYY
Dates of Travel
Destination Requested
Primary Passenger Name *
First MI Last
(As it appears on Passport/Government ID)
Date of Birth: *
MM / DD / YYYY
Mobile/Home Phone Number *
### - ### - ####
Email *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Passenger #2
First MI Last
(As it appears on Passport/Government ID)
Date of Birth:
MM / DD / YYYY
Passenger #3
First MI Last
(As it appears on Passport/Government ID)
Date of Birth:
MM / DD / YYYY
Passenger #4
First MI Last
(As it appears on Passport/Government ID)
Date of Birth:
MM / DD / YYYY
Room Category/Cabin Type
Resort/Cruise Line Requested
Special Request/Needs:
List any special request or needs required for the individuals listed. If there is a special need such as dietary or mobility, please indicate by passenger number.
Bedding Request, Flight Request, Allergies, Mobility Restrictions and/or Special Occasions
Travel Insurance *
Yes - I want to be covered
No - I'll take my chances
Unsure - Send Me a Quote
The cost of travel insurance is due at time of request. Please note that while some policies allow for insurance to be added at a later date, the benefits may be different and the cancel for any reason option may not be available. By declining travel insurance you acknowledge that all or part of your vacation may be non-refundable in case of trip cancellation and may be subject to penalties.
Total Quote
$ Dollars . Cents
Deposit Amount
$ Dollars . Cents
Deposit Due Date
MM / DD / YYYY
Final Due Date
MM / DD / YYYY
Payment Authorization
Sign and complete this form to authorize Twin Gemini's Travel Agency to process payment(s) to your debit/credit card listed below. Multiple charges may be processed for complex reservations using more than one supplier.

By signing this form you give us permission to process payment from your account for the amount indicated on or after the indicated date.

Please note: Quoted prices are not guaranteed. Prices are subject to change until payment or deposit is processed.
Cardholder Name *
First Middle Last Suffix
Enter name as it appears on the card. Additional verification may be required if cardholder is not a traveler on this trip.
Name of Travelers *
Enter the names of travelers that will be sharing the accommodations with you and/or that payment applies. Please note that each booking and/or person 18 and over is required to complete their own form, if they are the responsible party for their own booking.
Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Credit Card Type *
Credit Card

Card Number

For MasterCard, Visa or Discover, the CVV is the last three digits in the signature area on the back of the card. For American Express, its the four digits on the front of the card. For Gift Card, enter PIN or 000 if no PIN is listed.

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.
Payment Type *
Amount Authorized *
$ Dollars . Cents
Payment Plan *
Indicate if you authorize the card above to be charged minimum monthly payment. If selected Twin Gemini's Travel Agency will send a reminder at least 3 days before pending charge.
Final Due Date *
MM / DD / YYYY
I/we are aware of any cancellation policies and agree not to dispute or attempt to chargeback any of the signed for and acknowledged charges. Further more, I consent to provide an electronic signature rather than a handwritten signature in connection with my Credit Card authorization. By submitting my signature, I understand that my electronic signature will be binding as though I had physically signed this document by hand. I agree that a printout of this authorization may be accepted with the same authority as the original.
Electronic Signature *
Clear
Please use your mouse or touch screen to write your signature.
Type Signature Here *
No breaks or dashes needed
Date *
MM / DD / YYYY

Payment Authorization