Credit Card Authorization Form
Your privacy and security is important to us. The following form is secure.
If you are uncomfortable sending your credit card information over the Internet, please complete the form, print it out, and fax it to Mexico4Love.com at
(954) 252-2092
.
Traveler #1
Email address:
Legal First Name:
Legal Last Name:
Contact Phone:
Traveler #2
Legal First Name:
Legal Last Name:
Trip Details:
Resort:
Select Only One
Caribbean Reef Club
Desire Resort & Spa
Eden Bay
Grand Lido Braco
Grand Lido Negril
Hedonism II
Hedonism III
Hidden Beach
Punta Serena
Room Category
Travel Dates (Month,Day,Year):
Total Trip Price
$
Misc:
Lifestyle Site:
Screen Name on Site:
Travel, Special Request or Group Code:
Payment Information:
Credit Card Type:
American Express
MasterCard
Visa
Credit Card Number & Expiration:
Number:
Exp:
Security Code
(Last 3 or 4 digit numbers from back of card)
Cardholders Name (As Printed on Card)
Billing Address for Card:
Street
City
State
Postal Code
Country
Type of Payment:
Deposit
Final Payment
Installment Payment
Amount to be Charged:
$
in US Dollars
Date to Be Charged
December
January
February
March
April
May
June
July
August
September
October
November
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2006
2007
2008
2009
2010
Cardholder Authorization
I agree to the
Terms & Conditions
of GSA International Incentives, Inc and Mexico4Love.com. By completing the field below with my name and today's date, I authorize my credit card to be charged in the amount listed above.
Full Name
Today's Date
If submitting by fax, please sign your name above instead of typing it.
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