EmailMe Form - Destination Heal 2020 Payment Form

Please provide full name
(as it appears on Passport) *

Cell Phone # *

Credit Card Type *

MasterCard

Visa

Amex

Address *

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

Please select your room type. *

Standard Rate Double Occupancy $986 per person

Standard Rate Single Occupancy $1663

NON-REFUNDABLE Payment type *

Deposit

Monthly Payment

Balance

Amount *

Roommate(s) Name *

If none then write N/A.

TRAVEL INSURANCE PROTECTS YOUR PURCHASE
( only available to purchase within 7 business days of sent booking confirmation) *

Accepted

Declined

Add $61.99 to your deposit amount today or pay within 7 days of booking.

Terms & Conditions

Do you understand that the purpose of this credit card authorization form is to protect you, my valued client, as well as Travel By Design from credit card fraud. All information on this form will be kept strictly confidential. Please complete this form and return to Travel By Design. This form MUST be completed and returned before any credit card payments for travel on your behalf will be made. *

YES

NO

Any Comments or Questions?

Email *

Signature *

Clear

I understand an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Today's Date *

MM / DD / YYYY