EmailMe Form - DEBIT/CREDIT CARD AUTHORIZATION FOR TRAVEL

CENTERPIECE EVENT & TRAVEL GROUP

I understand this form confirms an agreed contract for Travel Service and the authorization of Payment for the Debit/Credit Card Listed. By completion of this form, I authorize Centerpiece Event & Travel Group to make payments on my behalf to selected suppliers for the purpose of securing my travel arrangements.

I understand that Debit Cards often impose a Daily Charge Limit and multiple payments may be needed to complete the full balance due. In the event this becomes necessary, Centerpiece Event & Travel Group is authorized to process payment and will notify me of payments made.

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NUMBER OF PEOPLE TRAVELING (Including You) *

NAME OF HOTEL(S)/TOUR/GROUP PACKAGE (If AIR ONLY RESERVATION PUT AIRLINE(S) CHOSEN) *

PERSONAL INFORMATION

PRIMARY TRAVELER'S NAME *

First Middle Last

As Listed On Government Issued ID that will be used for travel

DATE OF BIRTH *

MM / DD / YYYY

Email *

Phone *

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

Address *

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

DO YOU HAVE A PASSPORT? *

YES

NO

PASSPORT NUMBER

PRIMARY TRAVELER PASSPORT EXPIRATION DATE

MM / DD / YYYY

DO ALL MEMBERS OF YOUR PARTY HAVE A VALID PASSPORT? *

YES

NO

HOTEL/AIRLINE REWARDS NUMBERS YOU WANT ADDED TO YOUR RESERVATION

Please Specify Name & Reward Number (One per line) e.g.
Marriott Rewards # A0123456
United Mileage Plus # 0123456

PERSONAL INFORMATION OF TRAVELER # 2

NAME OF TRAVELER # 2

First Middle Last

As listed on government issued ID that will be used for travel. If no middle name put N/A.

DATE OF BIRTH

MM / DD / YYYY

DO YOU HAVE A PASSPORT?

YES

NO

PASSPORT NUMBER

PASSPORT EXPIRATION DATE

MM / DD / YYYY

EMAIL

CONTACT #

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

TRAVELER # 2 ADDRESS (IF DIFFERENT FROM PRIMARY

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

HOTEL/AIRLINE REWARDS NUMBERS YOU WANT ADDED TO YOUR RESERVATION

Please Specify Name & Reward Number (One per line) e.g.
Marriott Rewards # A0123456
United Mileage Plus # 0123456

TRAVEL INSURANCE

I understand that CENTERPIECE EVENT & TRAVEL GROUP recommends Travel Insurance to cover my vacation investment.

I understand that my purchase may not be refundable without full Travel Protection Insurance and that purchase of travel Protection Insurance can protect me from possible loss of my deposit and all future payments due to supplier bankruptcy/default, unexpected trip cancellation/interruption due to an accident, illness or death (of myself or family members), baggage loss, medical expenses and emergency air transportation costs. I also acknowledge that I am being made aware, that in order to obtain maximum coverage for pre-existing conditions, I must purchase Travel Protection Insurance within 14 days of paying my initial deposit (Limitations may apply).

** I acknowledge that if I decline the purchase of travel insurance being offered, any penalties or cancellation fees are my responsibility.
** I acknowledge that Insurance is provided by a third party company or supplier; in the event of a cancellation, my reimbursement will be determined by the terms of my policy and will be minus the cost of insurance.
** I acknowledge that I will refer to my specific insurance plan for coverage information.

Signature *

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**Please select the option of your choice based on the Insurance plans offered to you by your Centerpiece Event & Travel Group Agent. *

YES - I would like to purchase Travel Insurance at this time, please send me my travel Insurance quote now.

NO - I choose not to protect my travel investment. I will notify you if I change my mind and require a quote.

I may choose to purchase travel insurance at a later date, I understand restricions may apply. I will notify you when I am ready for my quote to be sent to me.

DATE TRAVEL INSURANCE CHOSEN OR DECLINED. *

MM / DD / YYYY

CREDIT CARD INFORMATION & AUTHORIZATION

DEPOSIT/PAYMENT AMOUNT BEING AUTHORIZED *

$ Dollars . Cents

NAME AS LISTED ON DEBIT/CREDIT CARD *

First Last

BILLING ADDRESS *

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

CREDIT CARD TYPE *

CREDIT CARD NUMBER *

EXPIRATION DATE *

MM / YYYY

I hereby authorize CENTERPIECE EVENT & TRAVEL GROUP (agent Tamara Finlayson-Fuller) to immediately charge my credit card in the above listed amount to make any and all payments directly to the supplier for all my approved travel plans. *

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DATE OF CREDIT CARD AUTHORIZATION *

MM / DD / YYYY

IMMIGRATION CHECK ACKNOWLEDGEMENT

We do not need to know if you have a criminal history, BUT it is important that you understand any travel restrictions based on your criminal history. International travel, including cruises, will require an immigrations check that may not allow you to travel if you were convicted of a felony, have back child support, a DUI or other legal issues. If you are on parole, you must have permission from your parole officer to travel. If you have finished your sentence, even if it was many years ago, we urge you to visit Travel.State.Gov and check for any restrictions to your destination. Some destinations have more strict rules than others. By submitting this form, you accept responsibility and absolve CENTERPIECE EVENT & TRAVEL GROUP as well as it's affiliates of any responsibility if you are denied travel due to criminal history OR lack of proper documentation.

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TRAVEL DOCUMENT ACKNOWLEDGEMENT

I understand that it is my responsibility to have proper travel documentation for the destinations I am traveling to. If I have questions about my travel documentation, I will refer to www.travel.state.gov and will ask questions of my travel agent well in advance of travel. CENTERPIECE EVENT & TRAVEL GP nor the agent, nor the tour operator in which I book my trip through are responsible for ensuring that I have proper travel documentation.

Signature *

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HAZARDOUS MATERIALS ACKNOWLEDGEMENT

Federal law prohibits the carriage of certain hazardous materials aboard aircraft in your luggage or on your person and could result in a fine. Visit www.tsa.gov and click on “prohibited items” for more information, or see below for additional info.

In instances where a single person (the group leader), is acting on behalf of a group of passengers in relation to the ticket purchase and check-in processes, that single person is assuming the responsibility of providing hazardous materials restrictions to each passenger traveling, and is responsible for providing the indication of understanding on behalf of the group. Federal law forbids the carriage of hazardous materials aboard aircraft in your luggage or on your person. A violation can result in five years' imprisonment and penalties of $250,000 or more (49 U.S.C. 5124). Hazardous materials include explosives, compressed gases, flammable liquids and solids, oxidizers, poisons, corrosives and radioactive materials. Examples: Paints, lighter fluid, fireworks, tear gases, oxygen bottles, and radio-pharmaceuticals. There are special exceptions for small quantities (up to 70 ounces total) of medicinal and toilet articles carried in your luggage and certain smoking materials carried on your person. Please refer to the full list of TSA prohibited items at http://www.tsa.gov/traveler-information/prohibited-items.

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TERMS AND CONDITIONS:

CENTERPIECE EVENT & TRAVEL GROUP acts only as an agent for airlines, hotels, tour operators, and other suppliers of services and shall not be held responsible for any injury, loss or damage caused by accident or event(s) beyond their control, or by any action or negligence of any persons who are not in their employ. Neither CENTERPIECE EVENT & TRAVEL GROUP or its agents will accept any responsibility for losses or additional expenses due to delay or changes in air, sea or other services due to sickness, weather, strike, war, or other causes. The right is reserved to make adjustments in the itinerary if deemed necessary.

*Prices are accurate at time of quote and are subject to change until trip is paid in full.

*Passports: All international trips require a Passport valid for at least 6 months beyond the date of departure. Any and all additional Visa's or travel documents required are the sole responsibility of the traveler.

*Air Travel : Flight details including departure times are always subject to change by the airlines and are not under the control of CENTERPIECE EVENT & TRAVEL GROUP. It is the travelers responsibility to check in for the flight 24 hours in advance and reconfirm all gates and times.

*FEES: I am aware there are potential Cancellation, Refund and Surcharge Policies and Fees by suppliers; 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. I understand that CENTERPIECE EVENT & TRAVEL GROUP will impose the following charges as applicable: 1.) All non-insured reservations, are subject to Cancellation Fees of $50 per adult, 2.) While requests for Extension of Payment Due Dates are usually denied by supplier, any such extension action if extended is subject to a $50 Service Fee, 3.) Booking Transfer Request will assess a Service Fees of $100 per adult: ALL fees will be applied to the credit card account as provided above.

*Travel Insurance : CENTERPIECE EVENT & TRAVEL GROUP offers Travel Protection that can help minimize the monetary loss incurred due to unforseen events beyond my control such as: cancellation, missed connections, baggage loss, trip delay, and especially medical emergencies.
4.) I also understand that it is my responsibility to pay any change fees imposed by the supplier if a correction to my name and/or date of birth is required due to providing CENTERPIECE EVENT & TRAVEL GROUP with incorrect or missing information.

* Cruise & Canada: If you are departing from a Canadian cruise port or you make a stop (scheduled or unscheduled) in a Canadian port and you are found to be inadmissible to Canada by a Canadian immigration officer, you may be denied entry at the border, miss your ship’s departure, and receive no refund from the cruise line.

*PLEASE NOTE: DUI convictions are inadmissible in Canada. All other FELONY convictions should refer to the Canadian State Department website for further information.

* Pregnancy: Please consult your doctor before travel as well as your respective airline/cruise line terms & conditions regarding pregnancy. Many airlines have restrictions on travel after a certain time. Also note, pregnant women entering their 3rd trimester are not permitted to cruise. It is your responsibility to advise CENTERPIECE EVENT & TRAVEL GROUP if you are pregnant.

I have read, understood and agree to the Terms and conditions of this agreement. *

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Please use your mouse, finger or stylus to sign above to acknowledge and agree to the above terms and conditions.