Credit Card Authorizations Web Site This form authorizes your MA World Travel agent to process payments and credit card holds for your vacation on your behalf. Please read the form carefully and complete all information. IMPORTANT NOTE: Please do NOT include your entire credit card number on this form. You will provide that to your agent by phone or in person. MA World Travel Agent * Jen Zinno Ashley Bivona Melissa Bretzius Brandi Constantine Debbie Dray Natalie Floyd Mindy Fontan Megan Harms Lindley Haun Amber Hoover Patty Hurley Amy Landrus Missy Logan Lang Mastro Christina Moore Grace Murphy Danielle Netta Erin Tietjen Andrew Smith Credit Card Type Visa Mastercard American Express Discover Other Last 4 Digits of Credit Card Number * Expiration Date * Cardholder Name (as it appears on the card) * Billing Address * Street Address 2 City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone Number * Email * I hereby authorize my MA World Travel agent to use my credit card listed above for the following purpose (check all that apply): Vacation deposit Other Authorization Choices Final payment on my vacation Credit card holds for dining and other reservations Prepayment of any dining or other reservations Travel insurance payment Any other components of my vacation not listed above Cardholder Authorization I certify that I am the cardholder listed above. Yes No I certify that I am the cardholder listed above. I authorize MA World Travel to process payments on my behalf using my credit card. Yes No I authorize MA World Travel to process payments on my behalf using my credit card. I certify that I will authorize specific charge amounts by sending an email to my MA World Travel agent prior to payment. Yes No I certify that I will authorize specific charge amounts by sending an email to my MA World Travel agent prior to payment. Signature By signing my first and last name in the box, I certify that I agree to conduct this transaction by electronic means. I also certify that I am responsible for payment of all charges listed above and will hold MA World Travel and its agents harmless with respect to those payments, and any other payments MA World Travel processes on my behalf. By signing my first and last name in the box, I certify that I agree to conduct this transaction by electronic means. I also certify that I am responsible for payment of all charges listed above and will hold MA World Travel and its agents harmless with respect to those payments, and any other payments MA World Travel processes on my behalf.
