EmailMe Form - Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM
Date *
MM / DD / YYYY
Please enter today's date.
Charge my card for: *
Airport Transfer Payment
Flight Only Reservation Payment
Group Leader Initial Required Deposit
Reservation Payment
Travel Protection Insurance Payment
Check all that apply.
Traveler Full Legal Name *
First Middle Last Suffix
Name as it appear on your reservation.
Cardholder's Name *
First Middle Last Suffix
Name as it appear on your credit card. Cardholder MUST sign below.
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 Number *
### - ### - ####
Email *
This will be used for mailing any electronic documents/itineraries.

Confirm
Is this an existing infividual or group Booking? *
Yes
No
If yes, then please enter group code or reservation number.
Please enter the group code or booking number.
Payment Details
Please provide payment details below
Authorized Amount *
$ Dollars . Cents
MINIMUM DEPOSIT is amount required today to initiate reservation. (The date of travel, number of paying guests and supplier terms will be factored in computing required deposit amounts.) This amount is included in Total Package Quote provided in Email. You MUST pay the balance in full prior to Final Due Date or if booking within 45 Days of Traveling.
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.
Authorization of Charges *
I do authorize
As named Cardholder; I Authorize: ***Destiney's Adventures LLC ***/Agent- LaTasha Williams to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package account for the Primary Traveler listed above. I agree not to fradulently initiate any chargebacks for any authorized payment(s) for travel services and/or purchases for the reservation or transaction above.
Authorization of Future Payments *
I Authorize my Future Payments
I want to use a different card for Future Payments
I will authorize, all future payments due towards Total Package Cost, to be charged to the above credit card with the same terms as disclosed.
Required *
ACCEPT: I have selected to PURCHASE Travel Protection Insurance as offered by Destiney's Adventures LLC. I have reviewed the Policy Coverage and accept that the policy meets my desired protection plus I understand when purchased it's non-refundable.
I have already purchased Travel Protection on my reservation.
I will make a decision to purchase Travel Protection at a later date, but no later than final payment due date.
DECLINE**: I acknowledge that I have received Travel Protection information and quote; I am WAIVING access to these coverage provisions by DECLINING to purchase the travel insurance offered by Destiney's Adventures LLC for my travel plans.
**If DECLINING: note that you will be required to complete and sign a Travel Protection Waiver form. Destiney's Adventures LLC will not be held liable for any financial losses incurred from failure to purchase insurance coverage. Insurance Premiums are always non-refundable.

Travel protection does not cover any Destiney's Adventures LLC change and/or cancellation fees incurred and/or applied to your booking.
Cancellation Policies *
I agree that should I cancel and did not purchase trip protection that I forfeit all money paid. I ALSO agree that there is a $50 per person cancellation fee that Destiney's Adventures LLC imposes for cancelled reservations that must be paid.
Your trip will not be cancelled until funds are received for the trip cancellation fee imposed by Destiney's Adventures LLC.
Terms and Conditions *
I agree to terms and conditions.
I have read and agree to the terms and conditions located here
.
Signature *
Clear
I understand an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Payment Details