Loyal Travel
2121 W Airport fwy Suite no 370 Irving Tx 75062
Tel 972 252 8888 Fax 972 252 8886
AUTHORIZATION TO CHARGE ON CREDIT
CARD
Note: Please fax a photocopy of your
Credit Card (front and back), and a photocopy of the card
holder's Passport or State ID (Driver's license) along with
this form.
Master Card
Visa American Express Discover
Passenger
Name:
Card
Holder Name:
Card
Number:
Card
Expiration Date:
Total
Amount (in US Dollars):
Billing
Address:
Billing
City:
Billing
State:
Billing
Country:
Billing
Zip:
Home
Phone:
Office
Phone:
Fax
Number:
In lieu of
my credit card imprint, I , hereby authorize Loyal Travel, Inc. and/or
their representative to charge my Credit Card for the amount
shown above. By signing below, I acknowledge the charges
described above. Payment in full to be made when billed or in
accordance with the policy of the company issuing the credit
card.