TRAVELAND
4270 Main Street
Bridgeport CT 06606
CREDIT CARD AUTHORIZATION FORM

203-371-1114-Phone 203-372-2556-Fax

Please complete the information below:

Cardholder's Contact Information, including billing address:
Card Holder's Name: ________________________________________________________
Street Address:   ___________________________________________________________
Suite/Apt. No.:   ____________________________________________________________
City:______________________________________________________________________
State/Province/District:   _____________________________________________________
Country:   _________________________________  Zip Code:_______________________
Billing Address Phone:  _________________   Alternate Phone:  _______________
Email Address:   ___________________@_______________________________________
 

I authorize Traveland to charge my credit card For payment towards the following services
Travel Date: __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Service provided for: (Please list passenger names)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Credit Card Type: ( ) American Express ( ) Discover ( ) Master Card ( ) Visa

Card Holder's Name (as it appears on card):_________________________________________
Credit Card Number:  __________________________________ Exp. Date:___________
Credit Card Security Code _____________ (3 digits on back of card, next to signature)
Authorized Amount $___________________ U.S. Dollars
Signature:_________________________________________________________________