“Please complete the form below to securely authorize payment for your travel arrangements with The Boarding Lounge.”

The Boarding Lounge

CREDIT CARD AUTHORIZATION FORM

TRAVEL ADVISOR INFORMATION

Name: Yomaris Matos

Phone Number: (407) 494-8196

Email: yomaris.matos@fora.travel

CLIENT / CREDIT CARD HOLDER INFORMATION

Client's FIRST and LAST Name

Phone Number

Email Address

Cardholder's Name

*Name as it appears on credit card

Credit Card Type

Visa

Mastercard

American Express

Discover

16-Digit Credit Card Number

Expiration Date

Month

Day

Year

For the "day" just put last day of the month

CVV

BILLING INFORMATION

Multi-line address

Country/Region

Address

City

Zip / Postal code

PAYMENT INFORMATION (Select one option below)

Payment in Full (Enter amount below)

One-time charge in the amount of:

Use this field only if you're making payment in full

Installment / multiple payments

(Deposit and future payments will be processed according to the agreed payment plan)

AUTHORIZATION TO CHARGE

I certify that I am the authorized cardholder for the credit card provided and authorize the travel supplier(s), as the merchant of record, to charge my credit card for travel services booked on my behalf by Yomaris Matos (The Boarding Lounge), an independent travel advisor of FORA Travel, Inc.

Charges may include a deposit, installment payments, and/or final payment in accordance with the supplier’s payment schedule and the payment plan I have agreed to.

I understand that all charges are subject to the travel supplier’s terms and conditions, including their cancellation and refund policies.

Electronic Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Today's Date:

Month

Day

Year

Note: The purpose of this form is to give Yomaris Matos / The Boarding Lounge authorization to make a CC transaction on behalf of the client, for a charge made by the supplier. For any questions about your booking, please email your travel advisor directly. The above payment is subject to the payment terms and conditions as stated on the trip itinerary or invoice.

Florida - Seller of Travel Registration No. TI125635