The Creole Poet - Credit Card Payment Authorization Form
NOTE: This form only provides your signature to authorize payment. For processing your payment, please send a secure (https) a copy of this signed form by text to Denise at 713.560.3284, scan and email to thecreolepoet@gmail.com
Name on Card, First, Middle, Last*
Phone Number (xxx) xxx-xxxx*
Billing address (The address the cr. card company sends the bill to you)
Street Address*
Street Address, Line 2
City*
Country*
State*
Postal Zip Code*
Your Email Address*
Payment Amount*
Vacation Protection* (everyone on the booking must purchase to have it)
Payment Notes: Enter payment notes here as needed
This Payment is For*
Card Info
I will be paying using*
*Check one box below as applicable for processing your payment
Authorization/Acknowledgement
By submitting this form, I do hereby authorize The Creole Poet to charge the above card in the amount indicated. The Creole Poet assumes no responsibility for changes made to a reservation if the payment fails to process. I am also acknowledging that I am the cardholder held under penalty of law and that I have read and agree with the terms and conditions including cancellation penalty.
Today's Date*
Booking Number if assigned. If not yet assigned show TBA in this box
Travel Supplier - for example, Carnival Cruise Line, Royal Caribbean, Funjet Vacations, United Vacations, etc.
Destination - for example Mexico, Jamaica, Bahamas, etc.
Travel Dates*
Full Name (First, Middle, Last) as listed on travel document: Passport (if required), driver's license and birth certificate if applicable (married ladies last as on Driver's License) If initial sign up for a cruise/vacation please list additional full names and DOB incl yr per booking in the notes box below
Date of birth incl year
OTHER PEOPLE IN YOUR CABIN: If initial sign up for a cruise/vacation please provide first middle last name as listed on travel document and date of birth including the year for each additional person listed on the booking
The Creole Poet is an IATAN accredited travel agency. Denise Prejean US Mail Address 4676 Highway 182 Opelousas, Louisiana 70570 Ofc 281.436.0405 Cell 713.560.3284 Email thecreolepoet@gmail.com Website www.deniselabrie.com or the www.creolepoet.com
Click this submit button to send this form to Denise Labrie at deniselabrie@sbcglobal.net to authorize payment your vacation booking.
Signature - please complete this form, print and sign in the box below then please take a cell phone photo of this signed form and text to Denise at 713.560.3284, scan and email to thecreolepoet@gmail.com
You may also print, complete, sign and return this Cr Card Authorization form below to provide your signature and cr card information for processing your payment or click here to download this form.
The Creole Poet
Address US Mail to: Denise Prejean
4676 Highway 182 Opelousas, Louisiana 70570
Please complete, sign & return by
scan & email or take a cell phone photo & email
to thecreolepoet@gmail.com
For processing your payment, please send a secure (https) encrypted email or file transfer scanned or cell phone photos/fax valid cr card (front& back) and drivers license (front) to text-713.560.3284, or email thecreolepoet@gmail.com
Credit Card Authorization/Disclosure Form
Please check one
_____Process
_____ File Purposes Only - Do Not Charge
I, ______________________, do hereby authorize The Creole Poet to charge my VI MC AMX DISC (indicate card type)_______
Credit card number _________________________________(last 4 digits if you prefer to call in), exp ________
Security code _________ (call in if you prefer)
Amount $____________(check one ___payment ___deposit (if purchasing vacation protection please include it with the deposit amount).
I have read and agree with the terms and conditions including cancellation penalty. ________ (initial)
Name on card: _______________________
My Credit Card Billing (address the credit card company sends the bill to you)
Address:
City/State/Zip:
Phone Number:
Email Address:
Vacation Protection - please check one
__ purchased $_________ per person each added to the deposit
everyone on the booking must purchase it to have it
___ declined
My booking information is as follows:
Booking/Reservation Number:
Destination:
Date of Travel:
Passenger Name(s)First/Middle/Last:
Date of Birth including the year for each passenger:
__________________________ __________
Signature Date
Please return completed form you may scan and email or take a cell phone photo and email to me at thecreolepoet@gmail.com
Enter process requested date here*
Final Payment Instructions*
Payment Plans enter start date here, if no payment plan requested, enter none *
Traveling with a group, please enter the name of the group you are traveling with here
PLEASE NOTE: This form ONLY provides your signature to authorize payment. Your cr card information must be provided by secure text, email, or fax for your payment to be processed on the booking.
As an IATAN accredited travel agent, I am registered with the Cruise Lines and Travel Suppliers to book your vacation and process payments directly into their system.
These companies all require travel agents have copies of the clients cr card and drivers license to process payments into their system and ensure that the credit card is valid. They also require that I have your signature to authorize payment.
The Cruise Lines and Travel Suppliers are considered merchants and the payments they process into their system have their own separate merchant acceptance guidelines and credit card verification measures that they are required to meet to ensure that a credit card is valid.
I have provided this secure online cr card auth form to obtain signature to authorize payment and I am required to request that copies of the cr card (front and back) and driver's license (front) be sent over a secure, encrypted text, email or fax to process payment. Travel Suppliers require copies of your cr card (front & back) and drivers license (front) be provided in order to process your payment on the booking into their system to ensure that a credit card is valid.
Please provide this information via a secure (https) encrypted email or file transfer scanned or cell phone photos/fax valid cr card (front and back) and drivers license (front) to Denise by text 713.560.3284 email thecreolepoet@gmail.com
Debit Cards: Please check with your bank to ensure that your daily limit will allow the amount to be charged to go through. Sometimes the bank will put a hold on the amount charged that will drop off in a few days.
Other Payment Plans will be processed as requested on the form submitted on or as close to the requested date as possible. Note: The last payment may be a partial amount based on the remaining amount due. A payment confirmation will be sent to you each time a payment is processed.
