Credit Card Authorization

Full Name (as it appears on passport or government-issued photo ID) *

Date of Birth *

(mm/dd/yyyy)

Independent Travel Agent

Customer Email

Customer Phone

Travel Insurance Waiver (Acknowledge that you have read the disclaimer below by initialing here)

For your protection, Travel Insurance is strongly recommended and available upon request from InteleTravel.com. You can enroll online for travel protection for Medical Expenses, Baggage Delays/Loss, Trip Delay or Cancellation, and other coverage, or your InteleTravel.com Independent Travel Agent can arrange coverage for you. For an online insurance quote and purchase, go to www.inteleTravel.com and click on Insure it.

Decline Travel Insurance (Acknowledge that you have read the disclaimer below by initialing here)

To decline recommended travel insurance, your signature on this insurance waiver form is required. Final Travel Documents (tickets, vouchers, etc.) cannot be sent to you prior to receipt of the signed insurance waiver.

Authorization (Enter your full name) *

I Authorize InteleTravel.com or the designated travel supplier to charge my card.

Select Method of Payment

American Express
Mastercard
Visa
Discover

Credit Card Number

If you prefer to give your credit card number over the phone, please enter all 9s and call (704) 785-1447.

Expiration Date

Billing Address

City

State

Zip *

CVV Code

Amount to be charged

Destination

Choose your room type

If you chose Cruise as your destination, choose your room type. If not, choose N/A.

Dates of Travel

Booking Number

Traveler's Names & Date(s) of Birth(s)

Please enter additional traveler's names with dates of birth who are included on this payment.

Accept Travel Insurance

I have ACCEPTED and authorized the travel purchases above, including travel insurance, and I am aware the insurance premium is not refundable.

Full Name (ONLY IF ACCEPTING TRAVEL INSURANCE)

Please enter your full name which serves as your signature. Enter N/A if this doesn't apply to you.

Date

Decline Travel Insurance

I have ACCEPTED and authorized the travel purchases above, and I understand that by checking this box, I am DECLINING TRAVEL INSURANCE. I have read and understand all cancellation charges and change fees related to the above travel arrangements, and that I may not be entitled to a full refund should my travel plans change. In case of cancellation of nonrefundable airline tickets or other arrangements, I agree to pay all applicable penalties according to the travel supplier's rules.

Full Name (ONLY IF DECLINING TRAVEL INSURANCE)

Please enter your full name which serves as your signature. Enter N/A if this doesn't apply to you.

Date

Travel Purchase Authorization (Acknowledge that you have read the disclaimer below by initialing here) *

Charges are payable ONLY to InteleTravel.com or the hotel, resort, tour operator, cruise line or other travel supplier. Independent Travel Agents may not accept and process charges through any other account, or accept checks, cash or other forms of payment.

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