VERIFICATION OF CREDIT CARD AUTHORIZATION FORM
Please
note that we cannot issue travel documents unless this form has been completed and returned to our office.
I, __________________________________
(print name) hereby authorize Trofino Tri-Star Travel, Inc. or, vendors used in conjunction with the vacation package to charge
the amount of $________________ to my:
VISA___ MASTERCARD___
DISCOVER___ or AMEX______
NO DEBIT or CHECK CARDS ACCEPTED
This
payment represents: Deposit_____
or Final Balance_______
Must
complete the Following:
Account Number:_______________________________________
Exp. Date:________
Verification Code:____________
Number of Passengers Traveling:____________
Trip Dates:_________________
Name as it
appears on the card:___________________________________ (Print Name)
Billing Address:
Street:__________________________
City:___________________________
State:__________ Zip Code:_________
Contact Telephone Number:___________________
E-Mail
Address:_________________________
(MUST INDICATE ONE CHOICE):
I have been notified of Insurance options and by signing below indicate my election to (MUST INDICATE ONE CHOICE):
1. Accept Insurance:___________ (Insurance may be purchased from our home page)
2. Decline Insurance:___________
REQUIRED:
YOUR SIGNATURE:____________________________________
Today's Date:______________
**Fax this complete form to: 814-535-1334
