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Jewish Travel Agency, division of EMCO Travel
4172 Ridgemoor Dr. N, Palm Harbor, FL 34685 | 727-254-4373 | info@jewishtravelagency.com
I, the undersigned (Print Name), Authorize EMCO Travel to charge my credit card representing payment for booking number (if available)
[/vc_column_text][vc_row_inner gap=”20″ el_class=”no-margin”][vc_column_inner width=”2/3″][vc_column_text]Print Name
[text* your-name][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]Booking Number (if available)
[text booking-number][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner el_class=”no-margin”][vc_column_inner][vc_column_text]Include Services:
[textarea services x2][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner gap=”20″ el_class=”no-margin”][vc_column_inner width=”1/4″][vc_column_text]To charge the amount:
[text* charge-amount placeholder “$”][/vc_column_text][vc_column_text]To My:
[select* menu-39 “Select Card” “Visa” “Mastercard” “AMEX” “Discover”][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/2″][vc_column_text]Credit Card Number:
[text* card-number][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/4″][vc_column_text]CVC Code:
[text* cvc size:4][/vc_column_text][vc_column_text]Expiration Date:
[date* expire][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner gap=”20″ el_class=”no-margin”][vc_column_inner width=”2/3″][vc_column_text]Billing Address:
[text* bill-address][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]City:
[text* city][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner gap=”20″ el_class=”no-margin”][vc_column_inner width=”1/3″][vc_column_text]State/Province
[text* state][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]ZIP Code:
[text* zip][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]Country:
[text* country][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner el_class=”no-margin”][vc_column_inner width=”1/3″][vc_column_text]E-mail:
[text* email][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]Please Confirm E-mail:
[confirm_email* confirm_email-803][/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text]Phone:
[text* phone][/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner][vc_column_inner][vc_column_text][acceptance acceptance-713 optional] I am aware of any cancellation policies and agree not to dispute or attempt of Chargeback any of the above signed for and acknowledged charges. [/acceptance][/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]
Fill and Print out this form and fax it back to us at 203-653-5586.
Important! Please include clear copy of credit card from both sides and driver’s license.
VERY IMPORTANT: Please be advised that your Credit Card statement will show “EMCO Travel”
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