EmailMe Form -

Payment Authorization

Name: Lead Traveler on Reservation *

First/Last Name

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 RL Travels; paid in prorated amounts not to exceed the sum total of approved charges. I understand Debit Cards often impose “Daily Charge Limits” and multiple payments may be needed to complete the full balance due; for which you will be notified if the situation occurs.

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 RL Travels will impose the following charges as applicable: 1.) All confirmed 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 is subject to a $50 Service Fee, 3.) Booking Transfer Request will assess a Service Fee of $100 per adult: ALL fees will be applied to the provided credit card account as provided below.

RLTravels 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. * *

I agree and accept the Terms and Conditions

Billing Information

Apply a payment for my trip to:

Please enter City/State/Destination

Departure Date

MM / DD / YYYY

Number of Credit/Debit Card Using to Make Payment

1

2

Payment Method

Name as it appears on the card

Prefix First Middle Last Suffix

Cardholder's Billing Address *

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

Cardholder's Phone Number:

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

Credit Card Type *

Credit Card *

Email

Minimum Deposit or Amount Authorized Today *

$ Dollars . Cents

You may also authorize RL Travels to make a recurring withdrawal of payment weekly, bi-weekly, monthly, or on your chosen date.

I authorize RL Travels to processing the recurring payment listed below on the following date. I will submit, in writing, the desire to skip a date or to cease the recurring authorization. The recurring authorization will continue on the amount set below until the total amount is paid in full. *

Day/Date for recurring authorization

Payment amount for recurring payment

$ Dollars . Cents

Would you like to receive email message alerts about your vacation? Including payment dates, balance and important reminders? *

Yes, please send me email messages

No, I do not wish to receive an email message

APPROVAL OF CHARGES AND DISCLOSURES* *

	I Agree/Understand
As named Cardholder; I Authorize: RL Travels/Agent- Free Russell-Louviere to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package account for the Primary Traveler listed above.
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.
As Primary Traveler; I understand I am responsible to READ the Mandatory Disclosure Email that will be generated upon submission. I ACCEPT: I have 24 hours from receipt of Disclosures to submit any dispute or cancellation due to content of email.
I understand that any changes to my reservation after deposit has been applied will incur a $35 penalty per request. i.e. Name, Add, Remove, Upgrade Room, Replace, etc. All cancellations will result in a $50 penalty per person, per booking.
I understand that as of June 1, 2009, a valid Passport will be required for everyone in my party, regardless of age, for all travel outside of the United States. If I do not obtain a passport, I am responsible for any cancellation fees.
Proper documentation is the sole responsibility of the traveler. Travelers who fail to present the necessary documentation, will be denied boarding, and be solely responsible for all fines, cancellation penalties, fees & additional expense.

Email For Receipt Confirmation & Mandatory Disclosure

Signature

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