EmailMe Form - Lavender Travel - Payment Authorization Form

Traveler *

First Last

Date of Birth *

MM / DD / YYYY

Email *

Please upload a picture of your passport (if applicable)

Airline Member Number and or Frequent Flyer #

Please provide the associated Rewards number for the airline being used for this booking (if applicable)

Traveler *

First Last

Date of Birth *

MM / DD / YYYY

Email *

Please upload a picture of your passport (if applicable)

Airline Member Number and or Frequent Flyer #

Please provide the associated Rewards number for the airline being used for this booking (if applicable)

Please indicate room type ie, Standard, Ocean View or Ocean Front (resort)/Interior, Ocean View or Balcony (cruise)

Authorization Form

By signing this form, I confirm that I have agreed to pay for travel arrangements.

Please ACCEPT or DECLINE *

ACCEPT

DECLINE

PAYMENT INFORMATION

Cardholder Name (as it appears on your billing statement) *

First MI Last Suffix

Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Billing Telephone *

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

Email - to receive payment confirmation *

Amount to be Charged *

$ Dollars . Cents

Credit Card

I hereby authorize Lavender Travel, an independent associate of Dugan’s Travels, LLC, and its representatives to charge my credit card as outlined above.

I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all agreed upon charges as well as any and all collection and legal fees.

This credit card is authorized for only the charges noted above. I agree that this payment information may be transmitted for charging directly to selected travel suppliers on my behalf by Lavender Travel, an independent associate of Dugan’s Travels, LLC; that multiple transactions may be made; and that transactions are not to exceed the sum total of approved charges.

I am aware of any potential cancellation, refund and surcharge policies and fees by suppliers and agree not to dispute or chargeback any of the above signed for and acknowledged charges without proper course of action.

Lavender Travel, an independent associate of Dugan’s Travels, LLC will not release personal information to any parties not listed on your finalized travel quote and will apply due diligence in maintaining records in a secured, safe location.

COVID -19 Liability Waiver:
By signing this agreement, I acknowledge the contagious nature of COVID-19
and voluntarily assume the risk I may be exposed to or infected by COVID-19 while traveling and that such exposure or infection may result in
personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while traveling may result from the actions, omissions, or negligence of myself and others.

Signature *

Clear