Payment Payment Form If you are human, leave this field blank. 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 * Melinda H. Donnie T. Neil H. Stacey A. Mandy Z. Leslie S. Rachel R. Adam W. Anna C. Unsure 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 Additional Comments? Special instructions, type of accommodations etc. * Signature (Use finger or mouse to sign) * Draw It Clear By submitting, you certify that you are the cardholder and are authorizing Dreams and Destinations, Inc. or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate. You also certify you have read the Terms & Conditions and the appropriate Travel Protection Plan details. Cancellation penalties may apply. Insurance is not refundable. This charge will be manually applied by your Dreams and Destinations travel professional to your reservation. If there are any issues, your agent will notify you. Please note, depending on the supplier used, that you may not see a charge from Dreams and Destinations on your credit card statement; the charge may come from our supplier and/or the airline directly. Payment may take 3-5 business days to fully process and be reflected on your statement. I authorize Dreams and Destinations, Inc to use the above information to charge my credit card the stated amount. Terms and Conditions * I Agree to the Terms
