Credit Card Authorization Form

Credit Card Authorization Form

emilyl@goldgellgetways.com * www.goldgellgetaways.com
Please note that your payment will not be processed until we receive your info, and enter it directly into a supplier's booking portal. We will then send you an email confirmation.
Card Holder Name

First NameLast Name
Credit Card Type

Other
Payment Type
Authorize Amount:
Reservation Number (if applicable:)
Credit Card Number
Expiration Date (MM/YY)
3-4 Digit Code
Card Holder's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Card Holder's Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Card Holder's Email
example@example.com
I hereby authorize Emily Lenihan with Goldgell Getaways or the travel supplier that my booking is through to charge my credit card for travel reservation and confirm that the information for the credit card and billing address is complete and accurate.
Signature:
PLEASE SELECT WHICH APPLIES AND SIGN BELOW ONLY IF YOU ARE SUBMITTING YOUR FINAL PAYMENT

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 my arrangements, I agree to pay all applicable penalties according to the travel supplier’s rules. I understand that Goldgell Getaways will be free of any charges, fees, or penalties made as part of this decision.
Signature
Should be Empty: