Credit Card Authorization


Travel Leaders/KaliKosmos Travel
Credit Card Authorization


Card Holder Name:  
 Street Address:  
City:   State:   Zip:  
Phone:  
Email:  

 

 Card Number:  
Exp:   Security Code:  

 

Upload a copy of the front of the card holder's ID

 

Upload a copy of the front of the card

 

Upload a copy of the back of the card

 

Total amount to charge: $  

 

By signing this form I authorize the above credit card to be on file for future payments and am aware that all payments carry with them restrictions and/or penalties once applied.

Sometimes charges will be made in international currency. Foreign purchase fees from credit card companies may apply.

Client assumes all risk and responsibilities associated with using debit cards for payments.

Leave this empty:

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Signature Certificate
Document name: Credit Card Authorization
lock iconUnique Document ID: 62648c37fc22e3d625bc1e7e0218e2693585954c
Timestamp Audit
January 1, 2023 10:07 pm CDTCredit Card Authorization Uploaded by Katie Hartman - forms@kalikosmos.com IP 172.59.120.197