Debit/Credit Card Authorization

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 *

I Authorize my Debit/Credit Card to be Charged.

PRT Agent/Referral Source *

* Indicates required field

Payment for which Individual or Group Trip? *

Dates of Travel *

Person(s) You Are Rooming With? *

Name as it appears on your card *

First

Last

Names as appear on passports *

Credit/Debit Card Type *

Visa Master Card American Express

Card Number *

Card CV2 # (3 digits on back of Visa, MC or 4 digits on front of Amex) *

Expiration Date *

Billing Address (If your Mailing Address is Different, please provide it in the Comment Section) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Amount Authorized/Payment Plan/Comment *

Submit

Note: Fields marked with * are required