|
|
This is a one time credit card payment authorization form.Sign and complete this form to Authorize Dazzling Deniece Travel Services to make a one-time debit to your credit card listed below.
|
| Full Name
*
|
|
|
| Trip Name (Tina Girls Trip, Vegas Trip, John Doe & Friends, etc)
|
|
|
| Type of Travel (Vacation package, Air, Train, Bus, Cruise, Hotel, Car rental, Excursion or Tour)
*
|
|
|
| If you're sharing a room with someone, list their NAME and DOB)
|
|
|
| Date of Birth
|
|
|
| Child name
|
|
|
| Child Date of Birth
|
|
|
| Email address
*
|
|
|
| Phone number
*
|
|
|
| Address
*
|
|
|
| City and State
|
|
|
| Zip Code
|
|
|
| Type of card (American Express, Mastercard, Visa, Discovery)
*
|
|
|
| Credit Card
*
|
|
|
| CVV
*
|
|
|
| Expiration Date (for day put 1)
*
|
|
|
| For the amount of $
*
|
|
|
| Comment (1st payment, 2nd payment, Etc)
|
|
|
| Initial
*
|
|
|
| Today’s Date
*
|
|
|
|
|
