Credit Card Charge Authorization Form printable pdf download

Credit Card Charge Authorization Form

I, _____________________________, authorizes All Japan Tours, a travel agency acting on

behalf of or thru instructions to my travel agent or representative, to apply charges to the

following credit card.

The charge is for the purchase of travel or any travel-related services for myself and the

following persons indicated below. In the event of any dispute arising from or charge back

from my credit card, I shall be fully and solely responsible for the settlement of payment.

All Japan Tours shall not be held liable in any manner. All the disputed and charge back

amounts must be paid back to All Japan Tours timely.

AUTHORIZED AMOUNT USD$

This amount is authorized to charge for □ TOUR FARE

□ DEPOSIT

Names - I agreed to make payment for the following passengers with the credit card bellow.

CREDIT CARD INFORMATION

ACCOUNT# :

EXP. DATE :

CVV :

CREDIT CARD TYPE : □ Visa

□ Mastercard

□ Amex

□ Discover

Card Holder Name (as it appears on your credit card) :

Billing Address :

City :

State / Region :

Zip Code / Postal Code :

Country :

Phone Number :

CARD HOLDER’S SIGNATURE :

Date

( As it appears on your credit card )

1-909-349-1736

PLEASE FAX THIS COMPLETED FORM TO OUR FAX AT

Credit Card Charge Authorization Form