credit card authorization form - Peach State Diamond Travel and Tours
Transcription
credit card authorization form - Peach State Diamond Travel and Tours
Post Office Box 3163 Lilburn, GA 30048 (844) 732-2412 info@peachstatediamond.com CREDIT CARD AUTHORIZATION FORM FAX TO: 844-732-2412 Peach State Diamond Travel & Tours is authorized to charge the credit card below for the following charges. Name of Trip or Destination ________________________________________________________ Date(s) of Trip: __________________________________________________________________ Amount to be charged $____________________ AM Visa MC Discover CC# _______________________________________________________ Exp. ___________ Three Digits on Back of Card _________________________ Print Name _____________________________________________________________________ Billing Address __________________________________________________________________ City, State, and Zip _______________________________________________________________ Phone Number __________________________________________________________________ Email _________________________________________________________________________ Signature ______________________________________________ Date ___________________ Signature authorizes Peach State Diamond to charge this credit card for the charges listed above. Credit card payments cannot be accepted over the telephone without your signature on this form. Insurance/ Policy Waiver Plan: Accepted Declined Please attach a copy of the front and back of the credit card listed above and photo ID with matching signatures. Without this information we are unable to process the charges.