IBroadlands Travel

 

Credit Card Charge Authorization Form

 

Please Complete:

 

Charge to: __AMEX  __MASTER  __VISA  _DISCOVER

 

Account:

 

 

Exp:

Month               Year

 

Name: (as it appears on card)________________________________________________________________

 

Billing Address:__________________________________________________________________________

                           Street                                                                                        City                              State            Zip

 

Telephone: (______) __________________________

 

Passenger Name(s):                                                                          Amount:

 

1. _______________________________________________          $_______________

 

2. _______________________________________________          $_______________

 

3. _______________________________________________          $_______________

 

4. _______________________________________________          $_______________

 

5. _______________________________________________          $_______________

 

                                                                        Total amount charge  $_______________

 

My signature below indicates authorization for IBroadlands to charge my card for the amount indicated above. I further acknowledge that
I have been informed of the cancellation and refund policies of IBroadlands and agree to the terms and conditions. I waive my right to
dispute these charges.

 

 

 

______________________________________________                ________________

Card Holder’s Signature                                                                   Date

 

Please provide:     1. Copy of Credit Card (Front and Back)

                                2. Card Holder Drivers License

Note: To ensure cards information clearly transmitted, please copy in lighter tone.