payment – Everlasting Memories Vacations

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Name on booking *

First

Last *

Last

Confirmation Number *

Email *

Phone Number *

Billing Address *

City *

State *

Zip Code *

I'm paying for the following *

Initial Deposit

Final Payment

Other Payment

Travel Protection

ACCEPT insurance*

DECLINE insurance*

Available at an additional cost.

Payment Amount *

amount to be charged during this transaction

Payment Type *

Credit Card

Debit Card

Card Type *

MasterCard

Visa

Discover

American Express

Card Number *

Expiration Month *

Expiration Year *

CVV Security Code *

Last 3 digits on signature strip (4 digits on front of AmEx)

Name as it appears on credit card (electronic signature) *

By submitting, you certify that you are the cardholder and are authorizing Everlasting Memories or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate. You also certify you have read the Terms and Conditions and the appropriate Travel Protection Plan details. Cancellation penalties may apply. Insurance is not refundable. This charge will be manually applied by the agency to your reservation. If there are any issues, an agent will get back to you. Please note that you may not see a charge from the travel agency on your credit card statement; the charge may come from our resort suppliers and/or the airline directly. Payment may take 3-5 business days to fully process and be reflected on your statement.

I authorize EM Vacations to charge my credit card and agree to the payment terms on my reservation. *

Yes

I authorize Everlasting Memories to use the above information to charge my credit card the stated amount. Completion of this form and checking this box signifies acceptance in lieu of my signature.

The travel agent I'm working with is *