Canary Credit Card Authorization and Insurance Decline/Acceptance

Canary Travel

Karen Kulow | 216-346-2773 | karenkulow@canarytravel.com
Credit Card Authorization and Travel Insurance Decline/Acceptance
To complete your transaction and confirm your arrangements, your signature on this authorization is required.
Client Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Reservation Number:

Travel Dates:
I have ACCEPTED and authorized the travel purchases below, including travel insurance, and I am aware the insurance premium is not refundable.I have ACCEPTED and authorized the travel purchases below, and I understand that by signing below, 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.
I authorize Canary Travel or its chosen Tour Operator/Supplier to charge the listed amount to the credit card. I have verified that all information contained in the confirmation I received is accurate.
Cardholder Signature*
Date*

MonthDayYear
Date
Calculation
Should be Empty:

Canary Travel