EmailMe Form - Credit Card Authorization

Today's Date *
MM / DD / YYYY
Primary Traveler Information-Name as it appears on credit card *
First Middle Last
The TSA requires that all airlines collect certain information from international and domestic travelers when making flight reservations. This information includes your full name as it appears on your passport or other government-issued identification, and which is printed onto your ticket and boarding passes. If the name on the travel documents does not match the identification you produce at the airport or port, you may be delayed and subject to extra security measures.
Primary Traveler Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Date of Birth *
MM / DD / YYYY
Cell Phone *
### - ### - ####
Email Address *
Secondary Traveler-- (Please Add Additional Traveler(s) And Their Dates of Birth
In The Notes Section Below).
Full Name- As listed on their Government identification or Passport
First Middle Last
The TSA requires that all airlines collect certain information from international and domestic travelers when making flight reservations. This information includes your full name as it appears on your passport or other government-issued identification, and which is printed onto your ticket and boarding passes. If the name on the travel documents does not match the identification you produce at the airport or port, you may be delayed and subject to extra security measures. For international trips please provide Passport information at least 30 days prior to trip.
Date of birth
MM / DD / YYYY
Cell Phone
### - ### - ####
Email Address
Are you rooming with someone? *
Yes
No
Name of person who will share your room.
First Last
Name and Date of Births of Additional Travelers (As it appears on government ID or Passport). Email address of additional guests. Any additional information or comments.
Are you a part of a group? *
Yes
No
Name of Group *
Type of Vacation *
All-Inclusive Vacation
Cruise
Destination Wedding
Hotel/Resort Only
US/ Hawaii Vacation
IF YOU ARE CRUISING-Requested Cabin Category
Inside Cabin
Ocean View
Balcony
Suite
IF YOU ARE CRUISING-Dining Requested
Early
Late
My Time Dining
Group Dining Selection
Hotel/Resort Requested Room Category
Best Offer/Less Expensive
Garden/Terrace/Tropical View
Partial Ocean View
Ocean View
Ocean Front
Suite
Junior Suite
Superior Room
Partial Ocean View Double
Partial Ocean View King
Ocean View Double
Ocean View King
Ocean View Diamond Club
Junior Suite Swim Out
Please Add Vacation Protection (Travel Insurance) *
Yes
No
If you elect to add Vacation Protection, please inquire for a custom quote.
Reason For Payment *
Initial Deposit
Vacation Installment Payment
Final Payment
Other
Credit Card
Payment Amount *
$ Dollars . Cents
Vacation Protection (Travel Insurance) Disclaimer *
Travel insurance is not required yet strongly recommended to protect your investment. Unexpected circumstances can occur at any time. A sudden health emergency for you or an immediate family member before or during your trip could alter the course of your vacation. Travel insurance is helpful should issues arise during you vacation like lost luggage, delayed flights, hotel issues, medical emergencies, trip interruption or any other unforeseen circumstances. I understand that if I elect to decline travel insurance I am responsible for any cancellation penalties and all out-of-pocket expenses that may occur.
Terms and Conditions *
I agree to the following terms & conditions. Thank you for your purchase with Breeze Travels LLC. To complete your transaction and confirm your arrangements, your submission of this authorization form is required. Charges are payable ONLY to the hotel, resort, tour operator, cruise line or other travel supplier designated by the above entity. I certify that I am authorized to use this credit / debit card and that I am able to make charges using this credit / debit card. I will not dispute the payment with my credit card company as long as the transaction corresponds with the terms indicated above. This payment authorization is for the goods and services described above. By my submission of this form, I give authorization to Breeze Travels LLC and the travel vendor being used to debit my credit / debit card for amounts listed above ONLY. I understand that if I elect to decline travel insurance I am responsible for any cancellation penalties and all out-of-pocket expenses that may occur. I will also make my own provisions in the event of an emergency while I'm away if I elected to decline travel insurance.
Breeze Travels LLC is registered with the State of Florida as a Seller of Travel Ref. No. ST41448
Signature Use Mouse Pointer or Finger to sign *
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