Instructions: 1. Fill out this
form on your computer screen and print it out 2. Sign where
indicated 3. Submit by mail or send it by Fax at 3039532143.
Please fill out the
following information and revert
via Fax.
In lieu of my
credit card imprint, I
(Name of Credit Card holder)
hereby
authorizeto
charge
(Travel Agent Name and Company)
my
Credit Card (choose one)
MasterCard
Visa Discov American Exp.
Card Number
Expiration Date
in the
amount of $
for payment of
transportation
of myself
and/or
for itinerary
(Full Name (s) of Passenger (s) if
other than cardholder)
as follows :
(Complete Routing Only)
Telephone
Home
Work
Email Address
Billing Address
NOTE : Please
provide Front & Back Photostat Copy
of the Credit Card and
