EmailMe Form - @MyTravelMischa Credit Card Authorization

Name on Credit Card *
First Last
Legal name as on government issued identification.
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
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

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:@MyTravelMischa to immediately charge my credit card the above amount, as needed to complete the reserved Travel Package.
Required *
ACCEPT: I have selected to PURCHASE Travel Protection Insurance as offered by @MyTravelMischa. 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 @MyTravelMischa 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. @MyTravelMischa will not be held liable for any financial losses incurred from failure to purchase insurance coverage. Insurance Premiums are always non-refundable.

Payment Details