Payment Authorization Form

Payment Authorization Form

Confirm you’re authorizing Slice of Tuscany to charge your card on file for trip deposits, final balances, and incidentals through Square.
Traveler Information
Full Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Trip Name or Travel Dates
Cardholder Information
Cardholder is the same as the traveler
Cardholder full name

First NameMiddle NameLast Name
Cardholder email
example@example.com
Billing Address
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Address Line 2
City
State / Province
Postal Code
Country
Payment Authorization
Square Payment Authorization

prevnext( X )
USD
Authorized charges
Authorization statement
I agree to the authorization above.
Authorized by
Signature and Date
E-Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: