payment authorization form

Please complete all information below to submit a payment for your reservation.

Refer to the BOOKING CONFIRMATION for the final payment due date and balance.

Contact your Travel Agent with any questions or concerns.

NOTE: If You have Pre-Authorized a Payment Card, You Can Save Time by Using This Form Instead: Pre-Authorized Card Payments

*Name(s) on Reservation

*Booking Reference# OR Group Name (if applicable)

Additional Information/ Request (optional)

PAYMENT INFORMATION

Card Type:

Expiration Date

Month

Year

CVV Number

Amount to Pay Now: $

*Do you want to SAVE this card for future payment convenience? If YES, you will be able to simply CALL or TEXT your Agent to make future payments for this reservation and will NOT need to resubmit this form. This authorization expires, and payment details purge, upon completion of travel or upon request. [SELECT ANSWER].

BILLING INFORMATION

Please charge my credit card for the amount indicated above for the referenced reservation. I understand all of the terms and conditions regarding this booking including cancellation policies, applicable penalties, and the availability of travel insurance.

If you are using a debit card with a daily spending limit, it is your responsibility to contact your bank to give them permission to authorize the transaction. If they require the name of the vendor and you are unsure as to who that is, please contact your Travel Agent at MaxLife Travel.

MaxLife Travel

(770)744-2977

Advisor@MaxLifeTravel.com