Credit Card Authorization

Your Information

First Name:

Last Name:

Phone

Email:

Are you traveling in a group or with association?:

Tour Name/Group Name:

Travel Agent/Group Leader:

Destination:

Travel Date:

Address

Street 1:

Street 2:

City:

State:

Zipcode:

Country

Address

Credit Card Information

Are You A Traveler?

Enter Traveler's Name:

Enter Traveler's Address:

Select Traveler's Country

Enter Traveler's Phone #:

How Many Other Traveler's Are you paying for?

List All Other Traveler's Name & Amount:

Payment Amount:

Total

Credit Card

Card #:

Exipration Date:

Credit Card

CVV:

Consent

I Agree: I have read and understand the terms and conditions of PALACE TRAVEL, and I agree to them completely. I authorize PALACE TRAVEL to charge in FULL the amount.

Credit Card Authorization

Credit Card Authorization Form