EmailMeForm
Credit Card Authorization Form
This form authorizes your agent and Travel On A Dream to submit payment on your behalf to travel suppliers. Information submitted here will not be processed until your agent submits it with the supplier. Payments received after 5:00 pm Eastern Time may not be processed until the next calendar day.
Name on reservation
*
First
Last
Agent Name
*
Unknown
Camille San Miguel
Cathy Bordelon
Deb Gustafson
Elizabeth St.Myers
Faith Fishel
Melissa Kyler
Tracy Whipple
Email
*
Name on card (if different)
Billing address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
Enter Credit or Debit Card in the Credit Card field. If using a gift card or Disney Visa Reward Redemption Card, enter that in the Other Card field.
Credit Card Only
Card Number
Expiration
MM
/
YY
CVV
What is this?
3 or 4 digit number printed on the back/front of your credit card
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.
Other Card
PIN Code for Gift Card
Please Note: If this is a debit card, your bank may have daily limits. We will just be notified that the card is declined. Contact your bank and find out your daily limit and/or ask for an increase while we process your payment.
Payment
*
Debit Card
Credit Card
Gift Card
Disney Visa Reward Redemption Card
Authorized Amount
$
Dollars
.
Cents
Only complete if partial payment
Payment
*
Deposit only
Final payment
Partial Payment
Special instructions
Authorization of Future Payments
*
I Authorize my Future Payments on this card
I want to use a different card in the future
If you authorize use of the same card, you you can email your agent to process all future payments.
Payments received after 5:00 pm Eastern Time may not be processed until the next calendar day.
I give my consent to Travel On A Dream via its agents to use my credit card information for booking the travel plans we have discussed.
Signature
*
Clear
Use your finger, mouse or stylus to sign your name.