Payment Payment Form Select Type of Payment Initial Payment Other Payment Final Payment Registry Please provide each traveler’s name EXACTLY as it appears in their passport and date of birth. How many passengers? * 0 1 2 3 4 5 6 7 8 9 10 11 12 Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Confirm Dates of Travel Departing * Returning * Package Information Are you a Destination Wedding Guest? No Yes Please give the name of the bride and groom in the comment section if "yes". Destination Wedding Couple Name of destination wedding couple Please select your Agent * None Anna C. Melinda H. Donnie T. Neil H. Stacey A. Mandy Z. Leslie S. Rachel R. Confirmation Number If unsure, please leave blank. Make sure to select the agent you are working with below. Payment Amount * Billing Information Name * Street Address * Street Address Line 2 City * State / Province / Region * Zip / Postal Code * Country * Email Address * Phone Number * Credit Card Information Credit Card Company * VISA Discover American Express Master Card Credit Card Number * Expiration Month * 1 2 3 4 5 6 7 8 9 10 11 12 Expiration Year * 2017 2018 2019 2020 2021 2022 2023 2024 Security Code * Insurance Travel insurance is not automatically included in your package and can be priced for you by your Dreams and Destinations Travel Consultant. Cancel for any reason insurance, if available, must be purchased with deposit. Catastrophic insurance options can be added after deposit, but are not cancel for any reason. Insurance is highly recommended as travel suppliers, airlines and resorts often charge fees for trip change/cancellation after payment has been made. Dreams and Destinations Travel Agency is not responsible for penalties or fees should you change or cancel your trip. The cost of insurance is nonrefundable and insurance policies are non-transferable. Are you purchasing travel insurance? * Yes No If no, please initial Terms and Conditions * I Agree to the Terms Additional Comments? Special instructions, type of accommodations etc. *
