Consumer Credit Card Authorization Form

Your completion of this authorization form helps us protect you, our valued customer, from credit card fraud. All information entered on this form is transmitted securely and will be kept strictly confidential. PLEASE NOTE: Fares are not guaranteed until ticketed.

CREDIT CARD

BILLING ADDRESS

For non-US/Canada billing addresses please enter “not applicable (N/A)” if your address does not have a state or postal code.

EMAIL

PHONE

TRAVELER INFORMATION

Fill out the following information for the person(s) traveling.

AGENT INFORMATION

TRAVEL INSURANCE

I understand and agree that travel arrangements are subject to non-refundable cancellation penalties. I further understand that as part of your travel services, you recommend that all travelers purchase some form of travel insurance to help protect their travel investment.

I understand that complete details of coverage, terms, limitations, and exclusions that may affect benefits payable are provided in the master policy and summarized in the certificate. Coverage may vary by state and country and may not be available in all states or countries. I agree to read my certificate carefully and note all restrictions that may apply. I acknowledge and agree that subject to your acceptance of this application and the payment of the premium in full, insurance coverage for all benefits, except the trip cancellation benefit, will begin on the scheduled date of departure on my covered trip. Coverage for the trip cancellation benefit will begin at 12:01 a.m. on the day after the completed application is received. I certify and represent that all applicants are medically able to travel on the date this insurance coverage is purchased. I understand that insurance benefits may not be payable due to pre-existing conditions.

TOTALS

SIGNATURE

I authorize Raptim Humanitarian Travel to charge my credit card for the total amount listed above pertaining to travel arrangements and any travel insurance that I have purchased. I understand that you will verify this information with the credit card company, and I declare that this information is correct.