Your Passport to the World

Payment Authorization

Name: *

CCV: *

Certify: *

By submitting, you certify that you are the cardholder and are authorizing the travel agency to charge the listed amount to the credit card through the Travel Supplier for your vacation. You also certify that you have verified that all information contained in the confirmations you received to be accurate. You also certify that you have received and read the Terms & Conditions that have been supplied to your from the Travel Supplier through your Travel Planner. All payments are processed directly with Travel Suppliers. If there is an issue, your Travel Planner will contact you. Payments may take 3-5 business days to fully process and appear on your charge statement.

Phone; *

Signature: *

Type of Payment: *

Deposit

Final Payment

Other

Credit Card: *

Expiration: *

State: *

City: *

Certify: *

I authorize the travel agency to use the above information to charge my credit card the stated amount. Completion of this form and typing my name below signifies my acceptance in lieu of my signature.

Confirmation Number *

Certify: *

Should I need to cancel my vacation, any refunded amounts will come directly from the Travel Supplier and will be credited back to my original form of payment, less any cancellation fees assessed by the Supplier. I also understand that should I cancel my vacation, any plans made on my behalf, by my Travel Planner, will also be cancelled.

Amount: *

Billing Address: *

Zip Code: *

This is a Payment Authorization form. Payments are processed manually by your Travel Planner. Please send payment authorization in advance so that your payment can be processed on time. All payments are processed directly with our Travel Suppliers.

Credit Card Number *

House of Mouse Travel