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CREDIT CARD AUTHORIZATION FORM |
LETTER OF AUTHORIZATION TO CHARGE CREDIT CARD |
| I authorize Destinations Belize to charge to the following described credit card the DEPOSIT or remainder due for guide services, lodging, transportation or purchase of products in the amount of: |
$___________________ U.S. Dollars ($1 USD = $2.00 BZD) |
Card Holder's Name On Card: ______________________________________________ |
| Credit Card
Type: _____
MasterCard _____ Visa Credit Card Number: __________________________________ Exp. Date:___________ |
| Cardholder's Contact Information, including billing address: |
| Street Address: ___________________________________________________________ |
| Suite/Apt. No.: ____________________________________________________________ |
| City:______________________________________________________________________ |
| State/Province/District: _____________________________________________________ |
| Country: _________________________________ Zip Code:_______________________ |
| Billing Address Phone: _________________ Alternate Phone: _______________ |
| Billing Address Fax: ____________________ Alternate Fax: _________________ |
| Email Address: ___________________@_______________________________________ |
| Signature:_________________________________________________________________ |
| Printed Name: ________________________________ Date:______________________ |
Destinations
Belize |
