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CREDIT CARD AUTHORIZATION FORM - Expired
Complete the information below to authorize Travelwise International to charge your credit card.
To receive a copy, enter your email address below.
Today's Date
MM
/
DD
/
YYYY
Agent's Name:
Please select
Aiza
Bless
Charleane
Jomarie
Keisha
Kristine
Marie Cris
Marielle
Max
Pia
Rollie
Cardholder's Name:
First
Last
Passenger Name:
If there is more than one passenger, please input their names in the space provided
Example: GONZALES/JOSEPH
Billing Address of Cardholder:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Amount to be charged:
$
Dollars
.
Cents
Credit Card
Card Number
Expiration
MM
/
YY
CVV
What is this?
3 or 4 digit number printed on the back/front of your credit card
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.
Travel Insurance:
*
Yes, please sign me up for travel insurance
No, I decline travel insurance and am willing to risk my entire travel investment
NOTE: The cost of travel insurance varies from state to state and is calculated by the age of the passenger and the total trip cost.
By clicking yes, you agree for Travelwise to authorize payment on your behalf.
Yes
No
Signature
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Email Confirmation
If you would like to receive an email confirmation, please enter your email address below.
Email Adresss
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