VIP Leisure Travel Vacation Information
Name
*
First Name
Last Name
E-mail
*
Phone Number
-
Area Code
Phone Number
Moble Number
-
Area Code
Phone Number
Billing Street Address
*
Billing City, State & Zip
*
Exp Date
*
Debit Card, Credit Card Authorization
Authorization is required to charge your credit card or debit card. Your completion of this authorization form helps us to protect you, our valued clients, from credit card fraud. All information on this form is kept strictly confidential. The "Yes" click below is representative of an Electronic Signature. This is a secured site.
Electronic Signature
*
YES : Credit Card / Debit Card Authorization is Approved
NO : Credit Card / Debit Card Authorization is Not Approved
Insurance
*
Yes, I elect to purchase travel insurance
No, I do not elect to purchase travel insurance and waive my rights to any claims
Submit
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