EmailMe Form - Credit Card Authorization & Travel Protection

Traveler 1:
Name as it appears on passport (if more than two travelers, please list additional traveler(s) legal name(s) as it appears on ID, as well as birthdate, and passport information in the additional comments box at the bottom of this form) *

First Middle Last

Passport number

Country of passport issue

Passport Issue Date

Passport expiration date

Date of Birth

MM / DD / YYYY

Gender *

Male

Female

Email *

Phone *

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

Invoiced Amount

$ Dollars . Cents

Traveler 2:
Name as it appears on passport

First Middle Last

Passport number

Country of passport issue

Passport Issue Date

Passport Expiration Date

Date of Birth

MM / DD / YYYY

Gender

Male

Female

Traveler 3, if applicable:
Name as it appears on passport

First Middle Last

Country of passport issue

Passport number

Passport Issue Date

Passport Expiration Date

Date of Birth

MM / DD / YYYY

Gender

Male

Female

Travel Protection Notification: The purchase of travel protection is strongly recommended to protect clients from certain situations that could cause this trip to be cancelled, interrupted, and/or delayed beyond my control resulting in a loss of time and money and that in the event that I cancel or change my trip myself that I may lose all or part of the money I have paid.

Please choose one: *

I accept trip insurance. I agree to all of the terms and conditions of the insurance program. I understand the coverage provided by the insurance company and will direct questions to the insurance provider.

I choose not to protect my investment with trip insurance. I understand that The Travel Bug Vacation Planners will be held free of any claims made as part of this transaction.

Please send me a quote for travel protection

Please check all boxes. If, after checking below, I find that I have made an error, I am responsible for any change fees assessed by the airline (or supplier used) to make the correction. *

I have reviewed the names, dates, times, and reservations made on my behalf by The Travel Bug Vacation Planners and I agree that they are correct and accurate.

Cancellation Penalties: I understand the cancellation/amendment policies of the vendor’s travel program that I have purchased. I agree to pay all charges, fees, or penalties, and hereby hold my travel agent free of any claims from changes I make.

I have checked all passports and acknowledge that they are all valid for at least 6 months beyond my return date; that they have at least 4 blank pages available; and that they are in good condition, without being bent, torn, or have any stray marks

If traveling domestically, please check above that you have confirmed the names as they appear on the traveler's ID, whether using a driver's license or passport

Cardholder's Name *

First Middle Last

Billing Address *

Street Address City State / Province / Region Postal / Zip Code

Upload

If requested, please upload a copy of both the front and back of your credit card.

Please check one:

Use this card when the final payment is due

I will be using a different card for final payment

I am the owner of this credit card and I agree to pay the amount shown. If I have a question regarding this charge, I will contact my travel agent and I agree not to dispute this charge with my credit card company. Please initial below *

Today's Date *

MM / DD / YYYY

Additional comments

Signature (sign with mouse, stylus, or finger) *

Clear

Thank you!