EmailMe Form - Payments

EmailMeForm

Name (as it appears on credit card) *
Amount to be Charged for this Transaction *
$ Dollars . Cents
Payment to be Applied On or After *
MM / DD / YYYY
Credit Card Billing Address *

Street Address City State / Province / Region Postal / Zip Code
Email Address for Receipt *
Phone # Associated with Credit Card *
### - ### - ####
Credit Card Type *
Visa
Mastercard
American Express
Discover
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.
I authorize Destination Luxe Travel to charge the above credit card for the following travel services *
Please provide information regarding the trip to which this payment should be applied.

Include group name, property you are visiting, other travelers, etc. to idenfity yourself.
By selecting "I agree", I authorize L. Roxanne Grewal of Destination Luxe Travel to apply payment on my behalf using the credit card information indicated in this authorization form according to the terms outlined above. This payment authorization is for the amount indicated above and is valid for one time use 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 so long as the transaction corresponds to the terms indicated in this form. *
I agree
Please provide your signature to acknowledge compliance with the above statement and authorize your payment: *
Clear
Please sign your name using your mouse or, if using a smart phone or tablet, with a digital pen or your finger.
Today's Date *
MM / DD / YYYY

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