EmailMe Form - Cardholder Authorization Form

Date Travel Starts *

MM / DD / YYYY

Date Travel Ends *

MM / DD / YYYY

Trip description *

Name *

First Middle Last Suffix

Email *

Phone *

### - ### - ####

I authorize Take Me Away Travel supplier(s) to charge my card selected below.

Select Card Type: *

Payment Amount *

Card Number *

Exp. Date *

CCV/CID # *

Name *

First Middle Last Suffix

(exact name as it appears on credit card)

VISA, MASTERCARD, AND DISCOVER credit cards have a three-digit (CVV) number. It is printed in the signature panel on the back of the Visa, MasterCard and Discover cards. The verification number is the last 3 digits on the right side of the panel.

AMERICAN EXPRESS credit cards have a 4 digit non-embossed number. It is printed above the account number on the front of your card. It may appear to the left or to the right, but it is always above your account number.

DEBIT CARDS or if your card has no verification code, enter 0000 in the CVV/CID field.

Billing Address:

This must be the address where your statement is mailed.

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Terms and Conditions *

I acknowledge - Terms and Conditions

- $200 cancellation fee per reservation.

- $500 cancellation fee for destination weddings and/or groups.

- Cancellation fees will be charged to the credit card on file within 48 hours of cancellation by Take Me Away Travel.

- The fee above does not include insurance premium or hotel/supplier cancellation fees

Covid-19 Travel Waiver *

I acknowledge - Covid-19 Travel Waiver

On the date indicated below, I requested that TAKE ME AWAY TRAVEL make one or more travel bookings on my behalf. As the worldwide COVID-19 coronavirus pandemic
remains ongoing at this time, I acknowledge that for this reason, and other reasons not reasonably foreseeable at this time, these travel plans may be interrupted or cancelled by the supplier that is providing them, a government entity or other third party over which Agency has no control. I further acknowledge that the supplier’s own cancellation, rebooking and refund policies, subject to any applicable law that is now or may later be in effect, will govern my rights and remedies, including my right to receive a refund, in such an event. Moreover, I understand that should I elect to purchase travel insurance, the terms of the policy will dictate whether, and to what extent, coverage for any financial loss may exist under the circumstances. By signing below, I hereby agree to hold Agency harmless and release it from any and all liability for any damages, including but not limited to monetary losses, I may incur as a result of such interruption or cancellation of these travel plans.

Signature *

Clear

I, the credit card holder, authorize the supplier to charge my card. I am are aware of any cancellation policies and agree to the terms and conditions.

Please double check all card information was entered correctly. *

Yes