Travel Queen Credit Card authorization Form
Travel Queen Credit Card authorization Form (Page 1 of 1)
This is a One Time Credit Card Payment Authorization Form.
Sign and complete this form to authorize Travel Queen to make a one time debit to your credit card listed below.
(Fields marked with * are required.)
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
Full name *
Amount authorized to debit *
The date authorized to debit on or after: *
This payment is authorized for (please describe goods/services) *
Billing address *
City,State, Zip Code *
Phone number: *
Email Address: *
Credit Card Information
Credit Card Type *
Cardholder name: *
Account Number *
Expiration Date *
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) *
I authorize Travel Queen to charge the credit card indicated in this authorization form according to terms outlined above *
Yes No
This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. *
Yes No
I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. *
Yes No
Electronic Signature *
Date signed *
List the agreed transaction amounts for airfare: *
List the agreed transaction amounts for hotel: *
List the agreed transaction amounts for rental car: *
List the agreed transaction amounts for excursion(s): *
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