Perfect Reflections Travel, LLC
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Debit/Credit Card Authorization: By submitting this form, you authorize Perfect Reflections Travel, LLC to debit/charge your card for travel services and you agree to the terms and conditions of Perfect Reflections Travel, LLC and
the Supplier who will be providing your travel services. Travel insurance is available for an additional fee and is highly recommended. Note that all payments are non-refundable unless you have travel insurance.
Payment for Travel Services
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I Authorize my Debit/Credit Card to be Charged.
I, the debit/credit card holder, authorize Perfect Reflections Travel, LLC to debit/charge my debit/credit card for my travel services. By checking this box and submitting this form, I agree to the terms and conditions of the Supplier who will be providing my travel services.
PRT Agent/Referral Source
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Indicates required field
Payment for which Individual or Group Trip?
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Dates of Travel
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Person(s) You Are Rooming With?
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Name as it appears on your card
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First
Last
Names as appear on passports
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Credit/Debit Card Type
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Visa
Master Card
American Express
Card Number
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Card CV2 # (3 digits on back of Visa, MC or 4 digits on front of Amex)
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Expiration Date
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Billing Address (If your Mailing Address is Different, please provide it in the Comment Section)
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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Amount Authorized/Payment Plan/Comment
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Submit
Note
: Fields marked with
*
are required