EmailMe Form - Submit A Payment

Romantics Travel
Jeff & Kimberly Jacoby
(817) 386-0701
jeff@romanticstravel.com

Submit A Payment Form

Please note this form does NOT automatically charge your card once submitted. Once your information has been submitted, it will be reviewed and processed with the supplier at the earliest possible date. Depending on when the form was submitted, it may be the next business day before payment is processed. You should receive an e-mail from us once your form submission has been received. You will also receive an e-mail receipt once your card has been charged.

Confirmation Number or Booking ID - (found on your receipt at the top) *

Name as it appears on your card *

Phone *

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

Email *

Credit Card Billing Address *

Street Address City State / Province / Region Postal / Zip Code

Credit Card Type *

Visa

MC

Amex

Discover

Credit Card

Payment Type *

Deposit

Payment

Final Payment

Other

Dollar amount to be charged *

$ Dollars . Cents

CARD HOLDER AUTHORIZATION
By submitting, you certify that you are the cardholder and are authorizing Romantics Travel or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate.

You also certify you have read the Terms & Conditions and the appropriate Travel Protection Plan details. Cancellation penalties may apply. Insurance is not refundable.

This charge will be manually applied by the agency to your reservation. If there are any issues, an agent will get back to you. Please note that you may not see a charge from Romantics Travel on your credit card statement; the charge will come from our supplier and/or the airline directly. Payment may take 3-5 business days to fully process and be reflected on your statement.

I authorize the travel agency to use the above information to charge my credit card the stated amount. Completion of this form and the initialing of this box signifies acceptance in lieu of my signature.By checking the box below and adding your signature, you indicate that the above amount is correct, you authorize the travel agency to charge your credit card for the specified amount, and you agree to the terms and conditions.

I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all agreed upon (as stated above) charges as well as any and all collection and legal fees.

By signing below, I agree to the accuracy of the information disclosed within this form and to the authorization to charge my credit card for the amount specified above. *

I AGREE

Signature *

Clear

Additional Comments or Passenger Information