Jeramie Credit Card Authorization

Agent Name *

Date *

I have hereby authorized Back Pocket Travel to charge my credit cared in the amount of $ *

To My *

Visa

Mastercard

Discover

American Express

For My *

Deposit

Full Payment

For my vacation to? *

Departing on? *

I am aware of any cancellation policies and agree not to dispute or attempt to chargeback any of the signed and acknowledged charges (cardholders initials) *

Cardholders Name as appears on card *

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Country

Card Number *

Expiration Date *

CVV# *

Please Select *

I hereby authorize Back Pocket Travel to utilize this card for future payments on this vacation as authorized in writing by the cardholder

I do not authorize Back Pocket Travel to utilize this card for future payments on this vacation. I will resubmit this form for all future payments.

Signature *

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