Payment — Senoia Travel

Credit Card Payment Authorization Form

Senoia Travel, LLC

Sign and complete this form to authorize Senoia Travel to debit your credit card listed below. By completing this form, you give us permission to debit your account for the amount indicated on or after the date this form is completed.

PLEASE COMPLETE THE FORM BELOW

Name on Card

First Name

Last Name

Authorized Amount

I authorize Senoia Travel, LLC to charge my credit card account indicated below for the following amount:

This Payment is For:

Credit Card Type:

Card Number

Expiration Date

CCV2

3 digit number of the back of Visa/Mastercard/Discover, 4 digits on the front of AMEX

Zip Code

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. 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.

Agree