Tamara Pay Vacation Confirmation Form 3-31

Name of your Trip*

Home Phone*

Cell Phone*

E-mail*

Trip cancellation insurance?*

Trip cancellation terms: Cancellation penalties could be up to 100% of the cost of your vacation. If I do not purchase insurance, I am responsible for any cancellation penalties.

Initial that you have read and agree to Trip Cancellation Terms*

Form of Payment

Credit Card Type*

Credit Card Number*

Name on Card*

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Expiration Date*

CVV (3/4 Digit Code on back)*

I authorize Love to Travel to charge my credit card for the amount of:*

Type Signature*

Signature