Share your information with Renee Edwards

Renee Edwards

The Travel Chick

<html>
  <body>
    <form-template>&#13;
	<fields><field type="text" subtype="text" required="true" label="First name" className="form-control" name="first-name"></field><field type="text" subtype="text" required="true" label="Email" className="form-control" name="email"></field>&#13;
		<field type="date" label="Date Field" name="date-1783901504887" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Full name - Please enter full legal name as seen on the credit card."/>&#13;
		<field type="text" required="true" label="Full name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Billing Address"/>&#13;
		<field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number&amp;nbsp;" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Credit Card Type" inline="true" name="radio-group-1783902377781">&#13;
			<option label="Visa" value="visa">Visa</option>&#13;
			<option label="Master Card" value="master-card">Master Card</option>&#13;
			<option label="American Express" value="american-express">American Express</option>&#13;
			<option label="Discover" value="discover">Discover</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Enter Credit Card Number" description="If you do not want to enter the entire credit card number, please enter only the last 4 digits and call your travel advisor by phone to communicate the entire number. " name="text-1783902672906" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Enter Credit Card Expiration Date" name="text-1783902715884" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Enter Security Code&amp;nbsp;" description="Security code is the last 3-digits on the back of your card by the signature panel or the 4-digits located on the front for American Express.*" name="text-1783902750246" subtype="text" className="form-control"/>&#13;
		<field type="paragraph" subtype="p" label="*Third Party authorizations from non-traveling payers may require additional documentation and proof of ID."/>&#13;
		<field type="paragraph" subtype="p" label=" *If you do not want to enter the entire credit card number, please enter only the last 4 digits and call your travel advisor by phone to communicate the entire number."/>&#13;
		<field type="paragraph" subtype="p" label="*PAYMENT AUTHORIZATION, TERMS, &amp;amp; CONDITIONS"/>&#13;
		<field type="paragraph" subtype="p" label="I hereby authorize The Travel Chick  to use this information to make any and all payments directly to the relevant travel suppliers for all my approved travel plans. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. I also reviewed all trip details and confirm that all itinerary information is correct; any alterations to the trip may result in extra fees. I acknowledge that I am purchasing this trip from a travel agency and not a hotel, airline, or other travel supplier directly, therefore, the transaction can’t be canceled due to service dissatisfaction. By signing my name below, I acknowledge that I have read and agree to the cancellation terms of all elements of my purchase. I am also responsible for having an up-to-date passport, travel documents, visas, and any other required proof of citizenship, and I am responsible for any consequences that may arise from not having them. I also understand that I need to check-in at least 2 hours before my flights, late check in will result in denial of boarding at my own expense. I understand that I am responsible for keeping track of all payment due dates. Late final payments will result in forfeit of deposit. I furthermore agree that my submission of this form electronically via email or facsimile shall constitute the execution of this agreement in exactly the same manner as if I had signed, by hand, a paper version of this document. I also agree to the consent to use my personal information and understand that by using The Travel Chick services for the booking of any travel services that certain personal identifying information may be conveyed to third parties relevant and necessary to the transportation and accommodation of your travel. The Travel Chick  shall not be responsible for the further use of said information by third parties by the customer."/>&#13;
		<field type="paragraph" subtype="p" label="Client Signature&amp;nbsp;"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

Enter the amount you would like to authorize:

Please add or choose card to authorize:

Sign and agree to the terms and conditions:

By signing below, I authorize The Travel Chick to charge the credit card provided herein.

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