Payment Authorization Form

I authorize Debra Gaines, ACC dba Paradise Travel Professionals and/or Cruises & Tours Unlimited to process a charge not to exceed the amount indicated below for travel components and services rendered by Debra Gaines, ACC dba Paradise Travel Professionals and/or Palm Coast Travel or one of its third party vendors. By submitting this form I acknowledge that I have been advised that the purchase of travel insurance is available to protect my travel investment in the event that non-refundable payments are lost due to unforeseen circumstances. I also acknowledge that Debra Gaines, ACC is NOT a licensed insurance agent and has not advised me on travel insurance plans, policies or coverages.

Your completed and signed form must be received in order to process any payments. Deposits will be charged immediately unless other arrangements have been made and agreed to in writing.

Full Name on Card

First Name Last Name

Billing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Alternate Phone Number

Area Code Phone Number

Last 4 digits of card number to be charged

Expiration Date

Date Deposit to be charged

Month Day Year Date Picker Icon

Deposit amount to be charged

Dated Final Payment to be charged

Month Day Year Date Picker Icon

Final Amount to be charged

By signing below, I authorize the above mentioned parties to charge my card listed on the dates listed below for the amounts specified. Any changes must be received in writing 48 hours prior to scheduled transaction. I understand that I will receive written confirmation of any requests and if do not, I may still be charged, due to lack of communication. I agree to immediately contact Debra Gaines, ACC via phone, text or email if I have not received confirmation of a change of payment processing.

Digital Signature

Clear