Credit Card Authorization Form

Credit Card Authorization Form

Cardholder's Name*
First Last
Credit Card Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone Number*
Mobile Number
Email Address*
Credit Card Details
Type of Credit Card*
Name as it appears on the card*
Credit Card Number*
Expiration Date*
Security Code*
Cardholder Declaration & Authorization
I hereby declare under the penalty of perjury that the information provided above is true and correct. I hereby also state that I have read and agreed to the terms and conditions stipulated in the booking contract. By checking this box, I hereby authorize Platinum Travel Insiders, LLC to charge payments due for the contracted amounts to my credit card account. I likewise confirm that the payments herein charged to my credit card account are valid and accurate despite the absence of my signature in the sales slip or terminal receipt for such payments. I further waive the requirement that Platinum Travel Insiders, LLC issue, submit or deliver to me a true and completed copy of the sales slip or terminal receipt covering these payments. This authorization will be cancelled after 5 days from receipt by Platinum Travel Insiders, LLC of my written notice to cancel it. I have also attached a copy of the front and back of my credit card to be sent via fax or email.
By typing my name below, I am confirming here the above in lieu of signature:*
First Last
Date Signed:*
MM slash DD slash YYYY
Please scan and upload copy of the front and back of your card
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
Email
This field is for validation purposes and should be left unchanged.

Credit Card Authorization Form

Credit Card Authorization Form

Credit Card Details

Cardholder Declaration & Authorization

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