Please print this form and fax or e mail it back to us with the required information.
E-Fax 845.350.5190
E Mail: donna@thehoneymoonplanner.net
I, (print name)________________________________________________ acknowledge charges made to my credit card for related charges described hereon and am aware of applicable restrictions and/or penalties as shown on such ticket(s) and/or coupons. I hereby authorize The Honeymoon Planner to charge travel expenses to the card below at my request.
X______________________________________________
Signature of Cardholder
Today’s Date ______________
________________________________________________________
Address
_________________________________________________________
City State, Zip
Card Number______________________________ exp. date_________________ VI MC DS AX
CID #__________ Amount $______________
______________________________________ ______________________
E Mail Address Phone
_____________
Number of Travelers
Do you have a passport? ___________________
Insurance is always strongly recommended.
Circle one:
Y - Insurance Desired-Yes I desire Travel Insurance
Date of Birth for all travelers insured: _________________________________________________
N - Insurance Waived-No, I choose to decline Travel Insurance
________ Initials
Credit Card Authorization Form
