SUSPENDED FORM

Agent Name: Roshon Gibson

Agent ID #: 20035694

Contact Information

Name

Address

Phone

Email

Travel Information

Departure Date

Return Date

Trip Origin

Trip Destination

Name of Resort/Hotel/Cruise ship

Booking/ Reservation#

Passengers Name:

Full names must be listed as they appear on your government issued identification and/or passport for all travelers. If additional space is needed use the space located at the bottom of the form.

Please include the information of the person completing the form, if that person is traveling.

Passenger 1

Gender

Male Female

Birth Date

Passenger 2

Gender

Male Female

Birth Date

Passenger 3

Gender

Male Female

Birth Date

Passenger 4

Gender

Male Female

Birth Date

All names and dates of birth listed above are as they appear on the respective government issued identification for each named person.

I agree

Travel Insurance

I have been informed of the cancellation policies for our travel services and have been made aware of the benefits of travel protection.

I agree and understand my investment is at risk if insurance is not purchased.

Passenger 1 Insurance Coverage

Accept Decline

Passenger 2 Insurance Coverage

Accept Decline

Passenger 3 Insurance Coverage

Accept Decline

Passenger 4 Insurance Coverage

Accept Decline

Passports/Visas

I have been advised of passport/visa requirements related to my trip.

I agree

Change/Cancellation

I have been advised of potential change/cancellation charges that may be implemented by the supplier in the event that I choose to cancel or change my booking after making the initial deposit.

I agree

Credit Card Information

Payment Type:

Full Deposit Scheduled Balance Due

Card Type:

Visa Mastercard Discover American Express

Cardholder Name:

Billing Address:

Card Number:

Expiration Date:
MMYYYY

CVV Number

VISA, MASTERCARD & DISCOVER credit cards have a three-digit (CVV) number. It is printed in the signature panel on the back of the Visa, MasterCard and Discover cards. The verification number is the last 3 digits on the right side of the panel. AMERICAN EXPRESS credit cards have a 4 digit non-embossed number. It is printed above the account number on the front of your card. It may appear to the left or to the right, but it is always above the account number on the front of your card. DEBIT CARDS or if your card has no verification code, enter 0000 in the CVV/CID field.

Amount Approved

I, the aboved-named authorized credit card user, give Astound Events & Travel Agency and its representative express authorization to charge my credit card for the purposes detailed above. I guarantee and warrant I am the legal cardholder for this credit card.

By signing below, I agree to the accuracy of the information disclosed within this form and to the authorization to charge my credit card for the amount specified above. I agree to this being my signature by electronic transfer to Astound Events & Travel Agency.

Digital signature
Sign using a mouse or if using a device with a touch screen use your finger or a stylus.

Clear

Date of signing

Additional Comments:

Note: Your card will not automatically be charged by completing this form; however, completing and submitting this form does give the agent the right to charge the card for the amount and purpose authorized.

Verification

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