EmailMe Form - Joe & Jeannine PAYMENT AUTHORIZATION (DEPOSIT)

Joe & Jeannine PAYMENT AUTHORIZATION (DEPOSIT)

LARIMAR TRAVELS (414) 248.8539

Joe and Jeannine are very excited that you are joining them in sunny Mexico. Please submit your payment below to reserve your room. The form allows for 2 travelers info. If you need more than that then we recommend you complete a second form and provide details in the comments box at the bottom. We welcome any questions if you need assistance completing the form.
I understand this is a disclosure of business practices and permissive payment agreement for the purchase of travel services. I agree that payments may be made direct to selected travel suppliers on my behalf by Larimar Travels; paid in prorated amounts not to exceed the sum total of approved charges. I understand Debit Cards often impose “Daily Charge Limits” and multiple payments may be needed to complete the full balance due. 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. I understand that Larimar Travels will impose the following charges when contractually applicable: all non-insured reservations are subject to Cancellation Fees of $50 per adult will be applied to the provided credit card account.

How many Adults in this room? *
How many kids under the age of 12 in this room? *
Traveler 1:
Spelling of names, including middle name, must EXACTLY match your Passport.* *
I have been advised that a passport is required for ANY international travel and it is MY responsability to obtain such document.
Date of Birth: *
MM / DD / YYYY
Preferred Email *
Preferred Contact Phone # *
### - ### - ####
Passport Country
Passport Expiration Date
Passport Number
Frequent Flyer / Rewards #
Traveler 2:
Spelling of names, including middle name, must EXACTLY match your Passport.* *
I have been advised that a passport is required for ANY international travel and it is MY responsability to obtain such document.
Date of Birth: *
MM / DD / YYYY
Preferred Contact Phone # *
### - ### - ####
Preferred Email *
Passport Country
Passport Number
Passport Expiration Date
Frequent Flyer / Rewards #
Room Type *
What is your arrival date to Cancun? *
MM / DD / YYYY
What date are you returning home? *
MM / DD / YYYY
Name as it appears in your card *
Billing Phone Number *
### - ### - ####
Card Type *
Enter your full Debit/Credit Card # *
Please enter your card number.
Card expiration date *
MM / DD / YYYY
For DD (day) enter the last day of the expiration month.
Security code *
3 digists code in the back of the card.
4 digits code in the front (if Amex)
Cardholder's billing address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Payment amount *
$ Dollars . Cents
Minimun deposit to book your room is $100 Per Person. Your final payment is due BY JULY 1ST, 2015.
Sum balance authorized *
$ Dollars . Cents
Remaining balance or agreed payment plan. If not sure, enter 0.00
How do you plan to pay for medical emergencies, if any were to come up before or during your vacation while abroad? *
Would you like to purchase travel insurance? *
Yes. I'd like to purchase trip insurance at an additional cost.
No, I choose not to protect my purchase
Important Fact: The average out-of-pocket cost of medical emergency transportation outside the U.S. is $25,000!

Please select the option of your choice based on the Insurance plans offered by Larimar Travels. If declined, any penalties or cancellation fees are your responsibility.
*Insurance is provided by a third party company or supplier; in the event of a cancellation, your will be reimbursed the total amount of payments made minus the cost of insurance.*
Refer to your specific insurance plan purchased for coverage information.
Bed request *
Double Beds
Queen/King Bed
Approval of charge (s)
Type your initials *
As named Cardholder; I do so Authorize: LarimarTravels/Travel Agent Will Medina to charge my credit card to suppliers required to complete the reserved Travel Package acount for the Primary Traveler listed above.
Would like to receive our monthly newsletter?
Yes, I would like to receive your newsletter
Have additional comments?
Emergency contact name and number *
Please provide a name and telephone number to enter in your reservation to be contacted in case of an emergency while you are traveling.
Terms and Conditions *
I Agree
Terms and Conditions:

• Larimar Travels acts only as an agent for airlines, hotels, tour operators, and other suppliers of services and shall not be held responsible for any injury, loss or damage caused by accident or event beyond their control, or by any action or negligence of any persons who are not in their employ. Larimar Travels can accept no responsibility for losses or additional expenses due to delay or
changes in air, sea or other services due to sickness, weather, strike, war, or other causes. The right is reserved to make adjustments in the itinerary if deemed necessary. Prices are accurate at time of quote and are subject to change until trip is paid in full
• Passports : All international trips require a Passport valid for at least 6 months beyond the date of departure. Any and all additional Visa's or travel documents required are the responsibility of the traveler.
• Air Travel : Flight details including departure times are always subject to change by the airlines and are not under the control of Larimar Travels. It is the travelers responsibility to check in for the flight
24 hours in advance and reconfirm all gates and times.
• Cancellations : Cancellation, revision and refund polices for changes or unused travel/components vary
and are subject to the policies of each supplier. Cancellation penalties can range up to 100% depending on
how close to departure the written notification is received. Air, insurance premium and no-shows are
always non-refundable. Larimar Travels reserves the right to charge a $35 per person
administrative fee payable before cancellation will be processed.
• Travel Insurance : Larimar Travels offers Travel Protection that can help minimize the monetary loss incured due to unforseen events beyond your control such as: cancellation, missed connections, baggage loss, trip delay, and especially medical emergencies.
Cardholder Signature Required *
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