GREAT ESCAPES TRAVEL, LLC

Fill out the secure form below to make a payment for your vacation.

The information submitted will be sent to your Travel Agent who will process your payment.

After your payment has been processed, you will receive an email confirmation of your payment.

If you have any questions, call 313-310-1630.

CREDIT CARD AUTHORIZATION FORM

First Name of Cardholder *

Last Name of Cardholder *

Street Address of Cardholder *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address of Cardholder *

List the names of guests who payment is being made for *

Reservation Number * 🛈

Name as it appears on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CCV/CSC/CVV Code (Credit/Debit Card Security Code) * 🛈

Payment Amount *

Payment Date * 🛈 +

By signing this form, I hereby authorize Great Escapes Travel, LLC to charge my Credit/Debit Card as detailed on this form. I also authorize Great Escapes Travel, LLC to charge a $25.00/transaction Declined Payment fee to my card each time a payment is declined. I take full financial responsibility should any problems arise with the Credit Card company or my bank.

Use your mouse to sign this form. *

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