Payment Authorization Form

Payment Authorization Form
Important: Please read carefully before continuing!

This form is required for EACH form of payment. If we are using more than one credit card, a new form will need to be filled out.

If you have more than 10 travelers, you will need to fill this out a second time for the remaining travelers.
Card Holder Information
I, First Name* Last Name* hereby authorize Hagan Hideaway Travel/Inteletravel or the travel supplier to charge my credit card below for the travel itinerary listed below:
For The TOTAL Amount Of $ (in USD)*
Please put the TOTAL amount of your trip, NOT the deposit amount. If your trip is being booked separately on multiple sites (flights, hotel, car rental, insurance, etc.), your card will be charged in separate transactions.
Name as it appears on card*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Associated with card *
Please enter a valid phone number.
Email*
example@example.com
Itinerary
Destination*
Departure Date*

MonthDayYear
Return Date*

MonthDayYear
Will your trip include a cruise?*

YesNo
Do any of these apply?*

U.S. MilitaryFirefighter/EMT/First ResponderAge 55+
Do you have dining time preferences?*

Early Dining (typically 5pm - 5:45pm)Late Dining (typically 7:30pm - 8:15pm)Flexible (typically 5pm - 9pm)Whatever is available
Do you want to prepay gratuities?*

Prepay GratuitiesPay Gratuities Onboard
Traveler Details
How many passengers are traveling in total?*
Please include yourself. Please only include those that you are paying for on this credit card.

Traveler #1 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
Passport Information
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #2 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
Passport Information
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #3 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #4 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #5 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #6 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #7 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #8 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #9 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Traveler #10 Information
NOTE: Please write the name as it appears on your passport (for international travel) or other government issued identification.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender*
Required for airline and cruise line manifests to match travel identification.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you rooming with?*
Please list all names that will share your room.
Please provide your room category selection. Please refer to your quote for the correct room description.*
Example: Ocean View Suite-King Bed OR Garden View-2 Queen Beds OR Balcony Ocean View-King Bed
If passport is required for travel, do you have a valid passport?*

Yes, traveler has a valid passportPassport expired, must renewDo not have a passportPassport not required for this trip
Passport Number
Passport information may be provided later if you haven't received yours yet.
Passport Expiration Date

MonthDayYear
Passport Issuance Date

MonthDayYear
Country of Issuance
Additional Information
TSA Precheck or Global Entry Numbers
Loyalty Member Numbers/Frequent Flyer Numbers

Payment Authorization Form

Card Holder Information

Itinerary

Traveler Details

Passport Information

Additional Information

Passport Information

Additional Information

Additional Information

Additional Information

Additional Information

Additional Information

Additional Information

Additional Information

Additional Information

Additional Information

Travel Insurance Advisory and Liability Disclaimer

Travel Protection and Travel Purchase Acknowledgment

Travel Protection Waiver and Travel Purchase Acknowledgment

Passport/Visa Acknowledgment of Risk

Please click "Continue" below. This will bring you to a page showing a preview of what you filled out. Please click continue at the bottom to submit.

Hagan Hideaway Travel

Travel Purchase Authorization For Non-Website Purchases. Thank you for your travel purchase.

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