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Travel Queen Credit Card authorization Form

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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): *