EmailMe Form - CREDIT/DEBIT CARD AUTHORIZATION FORM

Credit/Debit Card Authorization

Complete the form to authorize Great Escapes Travel to charge your Credit/Debit card as detailed below.

All information will remain confidential.

Reservation #(s)/Group Name *

If you do not have a Reservation # yet, type in the name of your Group or type "N/A" if this is for an individual reservation
If paying for more than one reservation, list all reservation #s separated with a semi colon (;)

Client Name *

Prefix First Middle Last Suffix

List ALL guests on the reservation for which payment is being applied.

If this payment is only for yourself, leave blank

Name (as it appears on card) *

Prefix First Middle Last Suffix

Billing Address *

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

Cardholder's Phone *

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

Credit or Debit Card *

Card Type *

Credit/Debit Card # *

Last four digits only

Expiration Month *

Expiration Year *

Deposit/Payment Amount *

$ Dollars . Cents

Indicate the amount that you authorize to be charged to your card.

Deposit/Payment Date *

MM / DD / YYYY

FUTURE PAYMENT AUTHORIZATION (only select one option) *

I will authorize by EMAIL, all future payments towards the balance for the Travel Package. I may opt to use a different Credit/Debit Card by submitting a new Credit Card Authorization Form.

I authorize Great Escapes Travel to charge my Credit/Debit Card on the date(s) and for the amount listed below until my balance is paid in full. I can amend this authorization by EMAIL.

Future Payment Start Date

MM / DD / YYYY

Indicate the date you authorize your Future Payments to begin

Bi Weekly Payment Dates

Indicate which two dates each month you authorize your card to be charged (ex. "1st & 15th of the month" or "2nd and 4th Friday of the month")

Bi Weekly Payment Amount

$ Dollars . Cents

Indicate the amount that you authorize to be charged to your card on a Bi Weekly basis

Monthly Payment Date

Indicate the day of the month you authorize your card to be charged.

Monthly Payment Amount

$ Dollars . Cents

Indicate the amount that you authorize to be charged to your card each month

Email for receipt of Confirmations *

You will receive an email with a confirmation for each payment made

Travel Agent *

Select the Travel Agent you are working with

Credit/Debit Card Authorization

I certify that all information listed above is complete and accurate.

I hereby authorize Great Escapes Travel to charge my Credit/Debit Card as detailed on this form.

I take full financial responsibility should any problems arise with the Credit Card company or my bank.

I understand that if I cancel or make changes to my reservation, Great Escapes Travel will charge a $50.00/person Administration Fee each time a change is made to the reservation.

I acknowledge that the details and terms and conditions under which I am purchasing Travel Services have been explained to me in full by my Travel Agent and/or Great Escapes Travel.

Signature *

Clear

Use your mouse to sign the form. Your signature constitutes your acceptance of the Terms and Conditions and the Fees outlined in this form