EmailMe Form - CREDIT CARD AUTHORIZATION

Authorization for MackeyMouse Travel to charge the agreed amount to your credit card. Your statement will reflect the vendor (ie, Disney, Funjet) that was used to purchase your vacation.

Today's Date *

MM / DD / YYYY

Name as it appears on your credit card *

Credit or Debit Card? *

Credit Card

Debit Card

Debit cards may require pre-authorization from your bank. If you are applying more than your daily limit it may be declined. Simply contact your bank to let them know how much will be charged.

Credit Card Type: *

Card Number *

no breaks or dashes necessary

CCV/CID# *

3 or 4 digits

Expiration Date *

mmyr

Amount to be charged today: *

Reason for today's charge: *

Deposit Only

Additional Payment

Final Payment/Pay in Full

I have reviewed all trip details and confirm that all information is correct any alterations to the trip may result in extra fees. I am aware of the cancellation policy for the supplier of this package. I acknowledge that I am purchasing this trip from a travel agent and not airline/hotel directly therefore transaction can’t be canceled due to flight/hotel service dissatisfaction. *

Yes

I understand that trip insurance may protect me from possible loss of money due to unexpected trip cancellation/interruption due to accident, sickness or death, baggage loss, supplier bankruptcy/default, medical expenses, and emergency air transportation costs per terms and conditions of Allianz. *

Yes

Purchase of Trip Insurance (optional, but recommended since trip non-refundable) *

Yes, please provide a non-obligation trip insurance QUOTE. I understand insurance must be added within 14 days of deposit date to cover any pre-existing medical conditions

I DECLINE trip insurance, and accept all terms and conditions regarding cancellation. I also understand that not all health insurance works outside the US and I take responsibility for my own care and confirming with my health insurance provider

I am aware of cancellation policies and agree not to dispute or attempt to chargeback any of the above signed for and acknowledged charges *

Yes

I guarantee and warrant that I am the legal cardholder of this credit card *

Yes

I am aware of cancellation policies and agree not to dispute or attempt to chargeback any of the above signed for and acknowledged charges *

Yes

I authorize MackeyMouse Travel to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; as long as the transaction corresponds to the terms indicated in this form. *

Yes

Signature *

Clear

use your finger or mouse to sign this form