EmailMe Form - Payment Authorization Form

Payment Authorization Form - Travel with Luisa, LLC dba Destination Weddings and More

Cardholder Details & Payment Authorization

Cardholder Full Name *

First Middle Last Suffix

Full name exactly as shown on the credit/debit card.

Cardholder Billing Address *

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

Payment Card Information *

Payment Details

Authorized Charge Amount (USD) *

$ Dollars . Cents

Please note that the amount you initially authorize must be greater than or equal to the minimum required deposit amount due in order to secure your booking with the supplier.

Description of Services *

Regular Payment

Booking #

Acknowledgment

Client acknowledges and agrees to all Terms and Conditions at https://destinationweddingsandmore.com/terms-of-service, including any cancellation or refund policies, which become effective between Travel with Luisa, LLC dba Destination Weddings and More ("Agency") and you (including all Travelers on the same booking) ("you," "your," "yourself" "our," "my," or "Travelers") upon your: (1) electronic or written signature; (2) payment authorization until terminated in writing by you or Advisor.

Signature *

Clear

Printed Name *

First Last

Date *

MM / DD / YYYY