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)
Print Name
[text* your-name]
Booking Number (if available)
[text booking-number]
Include Services:
[textarea services x2]
To charge the amount:
[text* charge-amount placeholder “$”]
To My:
[select* menu-39 “Select Card” “Visa” “Mastercard” “AMEX” “Discover”]
Credit Card Number:
[text* card-number]
CVC Code:
[text* cvc size:4]
Expiration Date:
[date* expire]
Billing Address:
[text* bill-address]
City:
[text* city]
State/Province
[text* state]
ZIP Code:
[text* zip]
Country:
[text* country]
E-mail:
[text* email]
Please Confirm E-mail:
[confirm_email* confirm_email-803]
Phone:
[text* phone]
[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]
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”