EmailMeForm
Amethyst Vacation Credit Card Authorization Form
Traveler Full Legal Name
*
First
Last
Legal name as on government issued identification.
Date of Birth
MM
/
DD
/
YYYY
Please enter Date of Birth for Primary Passenger
Billing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Please enter the address that is on file with the card.
Cardholder Phone Number
*
###
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###
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####
Email
*
This will be used for mailing any electronic documents/itineraries.
Confirm
Trip Destination
*
Please enter in your desired destination. If cruising with multiple destinations just put one location. ex: Bahamas
Is this a Group Trip?
Yes
No
If yes, then please name your Group Organizer
Please enter the name of the group organizer if unsure then put n/a.
Please List All Travelers Legal Names and Full Birthdate's to be included on this reservation (same room).
Full Legal Names Birthdate MM/DD/YY format of all passengers residing in the same room.
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 factered 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 75 Days of Traveling.
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.
Authorization of Charges
*
I do authorize
As named Cardholder; I Authorize: ***EMF Travel Services***/Agent- [Fist,Last Name] to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package account for the Primary Traveler listed above.
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.
Required
*
ACCEPT: I have selected to PURCHASE Travel Protection Insurance as offered by **EMF Travel Services***. 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 by **EMF Travel Services*** for my travel plans.
**If DECLINING: note that you may be able to purchase limited coverage up to 48 hours prior to travel. Ask your agent for restrictive details. **EMF Travel Services** will not be held liable for any financial losses incurred from failure to purchase insurance coverage. Insurance Premiums are always non-refundable.
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 $35 per person cancellation fee that **EMF Travel Services** 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 **EMF Travel Services***