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Carine Taylor TPI
Credit Card Payment Authorization
Square Dance Cruise - March 24-31 2019
Who may we thank for referring you to us?
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Guest(s) that you are paying for
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Name on Card
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Credit Card Type
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Visa
MasterCard
American Express
Credit Card Number
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Security Code
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Expiration Date (mm/yy)
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Billing Address & Telephone
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Please select your payment type
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Initial Deposit - $500 per person. Please note that checking this box indicates that you are aware that your deposit may be NON-REFUNDABLE depending on date of cancellation
Final Payment - due on or before Nov 24, 2018
Travel Insurance - non refundable
Flights / Advance Seat Selection / Hotel or Transfers
Other
Other
Amount to Charge
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Any comments?
TRAVEL INSURANCE - don't leave home without it! A quote will be provided to you to determine your requirements.
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Canadian Citizen
American Citizen
TRAVEL INSURANCE
for Canadians.
Due to Canadian provincial insurance licensing requirements, our agency may refer you to your local insurance agent.
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All-Inclusive Package (Most inclusive: Includes Trip Cancellation, Interruption, and Medical, as well as Baggage loss or delay, travel accident, etc.
Non Medical Package (Includes Cancellation & Interruption, but NO Medical coverage)
Emergency Hospital & Medical (Only covers medical while in Destination)
I don't know - please assist
I wish to DECLINE all coverage offered and will not hold my travel consultant responsible for any potential losses I may incur
TRAVEL INSURANCE
for Americans
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Basic - Trip Cancellation & Interruption of 100% of trip cost, emergency medical to $15,000
Select - Trip Cancellation & Interruption of 150% of trip cost, emergency medical to $50,000. ***NOTE*** Must be purchased within 21 days of deposit
I don't know - please assist
I wish to DECLINE all coverage offered and will not hold my travel consultant responsible for any potential losses I may incur
By e-signing here, I authorize Carine Taylor TPI to charge the above amount to the above credit card (NOTE - you can sign with your mouse if using a computer, and with your finger if using mobile device)
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clear
1) By signing this form, I have read and agreed to the terms and conditions of the travel agency and/or travel supplier. I will not dispute or attempt to charge back any of the above signed for and acknowledged charges.
2) No transactions will be performed until signature and permissions are received.
Carine Taylor, CTC
Personal Travel Advisor
Travel Professionals International
2627A Portage Avenue, Winnipeg, Manitoba, R3J 0P7, Canada
Head Office Telephone: 204.987.3333
Carine's Tel: 613.836.9623 | Fax: 613.383.0223
TICO Registration # 1576226