EmailMe Form - PAYMENT AUTHORIZATION for Travel Purchase

Date Time *
MM / DD / YYYY
Reason for today's charge *
Which Near & Far agent are you working with? *
Notes you want to share with Near and Far Travel about this payment today. (optional)
Primary Traveler's Name *
First Last
I understand that I am submitting payment, to be applied to the account of the listed Primary Traveler, whom is able to dictate dates, cost, and details of the applicable reservation code/price below.
Name (as it appears on credit card) *
First MI Last
Cardholder's Phone Number *
### - ### - ####
Cardholder's Billing Address *

Street Address City State / Province / Region Postal / Zip Code
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.
Amount Authorized today *
$ Dollars . Cents
MINIMUM DEPOSIT is the amount required today to initiate reservation. (The date of travel, number or 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
Signature *
Clear
Please use a finger pad/mouse to sign your name.
APPROVAL OF CHARGES *
As named Cardholder; I authorize the Travel Supplier to immediately charge my credit card the amount listed above, as needed to complete the reserved Travel Package account for the Primary Traveler listed above.
By authorizing this charge, I am agreeing to the Near & Far Travel's Terms and Conditions of Booking below -
Terms and Conditions
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.
INFORMATION ABOUT PASSPORTS *
I am aware that a passport book is required for all international air trips. Passports must be renewed prior to travel if it expires six (6) months after your return date or if there are not two blank pages available.
It is the responsibility of the traveler(s) to verify their passport books are valid with no less than six months to expiration after the travel return date and has two blank pages. Please visit travel.state.gov to renew your passport if needed.
INFORMATION ABOUT TRAVEL ITINERARIES *
I am have verified the spelling of all travelers names and dates of birth for accuracy. I am aware it it the responsibility of the traveler to verify the information of the travel itinerary matches the travelers' passports exactly.
It is the responsibility of the traveler(s) to verify their travel itinerary matches the passports exactly. Please notify Near and Far Travel Services if name spelling or dates need updated prior to payment. Errors could result in the cancellation of a booking or change fees.
Email for Receipt Confirmation *
Electronic Signature *
Clear
Please use a finger pad/mouse to sign your name.