Who is your Travel Agent?
Erica Van Stell
Jacob Van Dyne
Your Confirmation Number:
Please use your confirmation number,
the invoice number.
Your Name(s) *:
Your Email *:
Is this a Honeymoon Registry Gift?
If so, please provide the couple's name(s):
Credit Card Type *:
Credit Card Type
Payment Type *:
Other OR Final Payment
Honeymoon Registry Gift
Travel Protection *:
I understand that I CANNOT purchase the cancel for any reason insurance more than 14 days after my deposit is paid.
Additional Comments :
By submitting, you certify that you are the cardholder and are authorizing the travel agency or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate. You also certify you have read the Terms & Conditions and the appropriate Travel Protection Plan details. You certify that you understand that all payments may be nonrefundable. You certify that you understand that changes to your reservation may not be possible. You certify that you are responsible for investigating required documentation and identification and traveling with proper documentation and identification at all times. You certify that you are responsible for ensuring you are eligible to travel to all destinations.
This charge will be manually applied by the agency to your reservation. Please email, text, or call your Travel Professional with your CVV code as soon as you submit this form. If there are any issues, your Travel Professional will get back to you. Please note that you may not see a charge from the travel agency on your credit card statement; the charge will come from our supplier and/or the airline directly. Payment may take 3-5 business days to fully process and be reflected on your statement.
I authorize the travel agency to use the above information to charge my credit card the stated amount. Completion of this form and the initialing of this box signifies acceptance in lieu of my signature.
By checking the box below and adding your signature, you indicate that the above amount is correct, you authorize the travel agency to charge your credit card for the specified amount, and you agree to the terms and conditions.
Electronic Signature: (Sign with mouse or touch)*