EmailMe Form - Weekend Getaway Request & CC Payment

EmailMeForm

Primary traveler's name EXACTLY as it appears on your passport *
First Middle Last
Legal name as it appears on government issued passport.
Date of Birth *
MM / DD / YYYY
Please enter Date of Birth for Primary Passenger
Gender as it appears on your passport *
Email *
This will be used for mailing any electronic documents/itineraries.
Secondary traveler's name EXACTLY as it appears on your passport
First Middle Last
Legal name as it appears on government issued passport.
Date of Birth
MM / DD / YYYY
Please enter Date of Birth for Primary Passenger
Gender as it appears on your passport
Email
This will be used for mailing any electronic documents/itineraries.
Food Tour *
This an optional tour, but will be fun-filled and yummy!
Room Category *
Room will be based on availability and subject to change. Also, bedding requests are not guaranteed.
Additional information
Please provide additional information such as food allergy, special needs, etc
Payment Authorization
Your credit card will not be charged until you review and approve your trip quote.
Cardholder's Name *
First Middle Last
Legal name as it appears on government issued passport.
Credit Card

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Billing Address *

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

Please enter the address that is on file with the card.
Cardholder Phone# *
### - ### - ####
Authorization of Charges *
I do authorize the deposit amount listed in my quote
As named Cardholder; I Authorize: Michelle Scott with Indulgence Travel to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package account for the Primary Traveler listed above.
Photo and Image Waiver *
I agree and allow Indulgence Travel to post images on their social medial platforms
No, I do not allow Indulgence Travel to post image on their social media platforms
I understand and agree that Indulgence Travel may use photos of me taken during this group trip to promote on their website or social media pages, such as Facebook, Instagram and/or TikTok.
Authorization of Future Payments *
I Authorize my Future Payments
I want to use a different card for Future Payments
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.
Travel Protection *
ACCEPT: I have selected to PURCHASE Travel Protection Insurance as offered though Indulgence Travel. I have reviewed the Policy Coverage and accept that the policy meets my desired protection plus I understand all insurance premiums are non-refund
DECLINE**: I acknowledge that I have received Travel Insurance information and quote; I am WAIVING access to these coverage provisions by DECLINING to purchase the travel insurance offered though Indulgence Travel for my travel plans.
**If DECLINING: note that you may be able to purchase limited coverage up to 48 hours prior to travel. Indulgence Travel will not be held liable for any financial losses incurred from failure to purchase insurance coverage. Insurance Premiums are always non-refundable.
Signature
Clear
I, the credit card holder, authorize my travel advisor, Michelle Scott, of Indulgence Travel, to apply my payment to their accredited travel supplier. By submitting this payment, I agree to the terms and conditions of both the agency that I am booking with, and the travel supplier of the itinerary that has been recommended to me and that I have opted-in to. I understand the itinerary that I have chosen.

Payment Authorization