EmailMe Form - A-PAYMENT AUTHORIZATION FOR Cruises

LS Travel Agency Payment Authorization Terms & Coinditions:

As Primary Traveler On Reservation and on behalf of all guests on reservation: I understand this is a disclosure of business practices and permissive credit/debit card payment agreement for the purchase of travel services. I agree that payments may be made direct to selected travel suppliers on my behalf by LS Travel Agency; paid in prorated amounts not to exceed the sum total of approved charges. I understand Debit Cards often impose “Daily Charge Limits” and multiple payments may be needed to complete the full balance due; for which you will be notified if the situation occurs.

FEES: I am aware there are potential Cancellation, Refund and Surcharge Policies and Fees by suppliers; I understand it is my responsibility to read and abide by the policies, terms and conditions as posted on supplier documents and agree not to dispute or chargeback any of the above signed for and acknowledge charges without proper course of action.

LS Travel Agency will not release personal information to ANY parties not listed below, unless provided in writing as an Emergency Contact and will apply due diligence in maintaining records in a secured, safe location.

Client Code:

For Office Use Only

Cruise Only Required Information

Cruise Line?

Departure date:

MM / DD / YYYY

Cabin Category

Interior

Ocean view

Balcony

Suite

Return date:

MM / DD / YYYY

List ALL traveler(s) on the reservation for which payment is being applied. Include Full Name & Date Of Birth for each traveler below.

TRAVELER(s) Information:

I am submitting payment to be applied to the account of the above traveler.

Credit Card Holder Information:

Name: *

First Last

(Exactly as it appears on credit card)

Middle Name: *

As it appears on CC. Type N/A if it doesn't apply

Date of Birth *

MM / DD / YYYY

Billing Address On CC: *

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

*REQUIRED: (The Address above should match what your financial institution has on file)

Phone: *

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

Credit Card Type

Credit Card Number: *

Your Statement will show Mark Travel Corp or Funjet as the payee.

Expiration Date: *

MM / YYYY

CVV#: *

3-digit number on the Back of card for Visa, MasterCard & Discover
4-digit number on the Front of card for AMEX

Payment Type: *

Deposit Amount

Payment on Existing Reservation

Payment In Full

Other explanation how to apply monies?

TRAVELER(s) TRAVEL INSURANCE Deposit/Payment Included:

List ALL traveler(s) on the reservation for which TRAVEL INSURANCE is being applied. Please include: Legal Full Name & DOB for each traveler.

I am submitting payment to be applied to the account for the traveler(s) listed above for Travel Insurance.

VACATION PROTECTION INSURANCE: All guest must sign a disclosure Accepting or Declining Travel Portection Insurance prior to issuance of final documents. Cost of Insurance Premium is never refundable once purchased.

Do you want Travel Insurance Coverage? *

YES. I want Travel Insurance Coverage included

NO. I Do Not Want Travel Insurance Coverage included at this time.

CREDIT CARD HOLDER Total Amount Authorized:

Credit Holder Total Amount you are authorizing including Travel Ins coverage and payments for ALL traveler(s) listed above. *

$ Dollars . Cents

PASSPORT INFORMATION: If your travel plans include International Flight, please fill out the additional passport questions below.

Do You Have A Valid Passport? *

Yes. I Have A Valid Passport

No. I am in the process of applying for my passport

Other

Alert: It is strongly suggested that all travelers exiting the US, in any form of transportation have a valid passport book. In the event of an emergency, no other documents will be accepted for inbound foreign flights. Travelers are responsible for meeting all documents requirement for travel. For complete regulations regarding passport requirements, visit www.travel.state.gov.

If yes, Passport Expiration Date?

MM / DD / YYYY

Other Passport Explanation?

Full Name On Passport:

First Middle Last

(Exactly as it appears on your passport) N/A If you do not have a Middle Name

Passport Expiration Date?

MM / DD / YYYY

Country of Citizenship

USA

Canda

Other

Other Citizenship?

Passport Info for Additional Traveler(s) on this reservation:

Please list each person passport Legal Full Name, Expiration Date, DOB & Citizenship.

Please select all that apply for traveling party.

Special Occasion?

Please include dates and additional details below.

Special Occasion Date?

MM / DD / YYYY

Emergency Contact Name (Not Traveling With You):

First Last

Emergency Contact Phone:

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

Client other request(s)?

Please be as detailed as possible.

APPROVAL OF CHARGES:

As named Cardholder, I authorize Lisa Streater at LS Travel Agency to immediately charge my credit card the above amount including any additional payments required, as needed to complete the reserved Travel Package account for the primary travelers listed above.

FUTURE PAYMENT AUTHORIZATION:

I will authorize by Email, all future payments due towards Total Package cost, to be charged to the above credit card with the same terms as disclosed. I may opt to use a different credit card simply by submitting a new authorization form.

Signature *

Clear

Use your "mouse" to sign your name.

Print Name: *

First Last

Today's Date: *

MM / DD / YYYY

Email: *

For receipt confirmation and any other documents reference your trip.

Lisa Streater ~ LS Travel Agency
Phone: 240-431-7230
Email: info@lstravelsonline.com
Web: www.lstravelsonline.com