Loyal Travel Credit Card Authorization

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 _________________________________________ Card Holder's Signature Credit Card Billing--By checking this box you are authorizing Loyal Travel Inc the right to charge the indicated credit card number for invoice charges on your Air Ticket purchased from Loyal Travel Inc. Visa Master-Card Discover American Express Credit Card Number:______________________ Exp. Date: __________

LOYAL TRAVEL