Credit Card Authorization Form.
SECTION 1 — CARDHOLDER INFORMATION
Cardholder Name (as on card)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 2 - CREDIT CARD INFORMATION
Card Type:
*
Visa
Mastercard
American Express
Discover
Last 4 Card Number
*
Expiration (MM/YY)
*
Billing ZIP
*
SECTION 3 — TRAVELER & BOOKING DETAILS
Is the cardholder also the primary traveler?
*
Yes
No (list travelers below)
Traveler Name(s)
Cornerstone Agent Name
*
Destination
*
Brief list
Description of Charges
*
Brief description
Travel Dates
*
Total Amount ($)
*
Do not exceed amount
SECTION 4 — AUTHORIZATION & TERMS
I, the undersigned cardholder, am the legal owner of the credit card listed in Section 2 and am fully authorized to use it I authorize the Cornerstone Travel agent named in Section 3 (the "Agent"), and Cornerstone Travel (the "Company"), to charge my credit card for the total amount disclosed in Section 3, including all travel services, fees, taxes, and supplier-imposed charges associated with this booking. I further authorize the Agent and the Company to charge my credit card for any additional travel-related charges that I separately authorize and approve in writing (including by email or electronic signature), such as itinerary changes, upgrades, add-ons, or supplier rebookings. I acknowledge that travel suppliers (airlines, cruise lines, hotels, tour operators, etc.) maintain their own cancellation, refund, and change policies, which may include non-refundable deposits and change fees. I accept full responsibility for all supplier-imposed charges and penalties. Commissions, service fees, and non-refundable supplier charges are not refundable by Cornerstone Travel. I agree not to initiate a chargeback, dispute, or reversal against any charge I have authorized through this form (or subsequently approved as described above) so long as the corresponding services were made available to me or my designated traveler(s). If the traveler(s) listed in Section 3 differ from me, I affirm that I have knowingly authorized third-party use of my card and accept full responsibility for all resulting charges. Any unauthorized or fraudulent dispute may be contested by Cornerstone Travel and referred for collection or reported to the relevant authorities. Cornerstone Travel reserves the right to require additional identity verification and to decline any booking where fraud is suspected. By signing below, I certify that all information I have provided is true, accurate, and complete, and I agree to all terms of this Credit Card Authorization.
SECTION 5 — CARDHOLDER SIGNATURE
Cardholder Signature
*
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
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