Jewish Travel Agency, division of EMCO Travel

4172 Ridgemoor Dr. N, Palm Harbor, FL 34685 | 727-254-4373 |

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:
[text* expire]

Billing Address:
[text* bill-address]

[text* city]

[text* state]

ZIP Code:
[text* zip]

[text* country]

[text* email]

[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”

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Jewish Travel Agency

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    © 2019 Jewish Travel Agency.
    EMCO Travel LLC, DBA Jewish Travel Agency is registered with State of Florida as Seller of Travel Registration No. ST36902
    California Seller of Travel Registration number 2079011-40.