One Time Credit Card Payment Authorization Form - By completing and submitting this form you are authorizing Lost in Adventure Travel to process a payment(s) to the credit card(s) listed below. Your account will be charged the amount listed below on or after the date this form is completed or when specified below. This permission does not authorize Lost in Adventure Travel to process any additional debits or credits to your account related to your current travel or any other reason.

Who is your Travel Agent? *

Reservation Number or Check in Date *

Destination *

First Name *

Last Name *

Enter all information as it appears on your Credit Card billing statement

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Credit Card Information

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code (3 or 4 digits- Back of your card) *

Some suppliers require a credit card for select dining and event reservations. Lost in Adventure Travel will keep your card number securely on file, until you travel after which your information will be safely erased from our records. If you do not want to us to do this, please type please select the option below

Payment Info-

Please allow 48 hours for payment to process. If you need immediate attention to your payment, please contact your vacation planner after submitting this form.

Amount due *

Preferred Payment Date * +

Optional Information

Additional Comments for your vacation planner

Electronic Signature

This is YOUR ELECTRONIC SIGNATURE allowing a one time credit card payment authorization as instructed above. By completing and submitting this form you are authorizing a payment(s) to the credit card listed. You give permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Please type YOUR NAME in the box below to authorize

Type Name for Signature *