Enter your card number without spaces or hyphens. This data is encrypted on our secure servers to meet PCI compliance standards. DO NOT EMAIL YOUR CREDIT CARD NUMBER. Thank you.

Name

First Name

Last Name

Email Address

Cardholder Name

Billing Phone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Optional Instructions/Questions

Credit Card Type

Credit Card Number

Enter your card number without spaces or hyphens. This data is encrypted on our secure servers to meet PCI compliance standards. If you do not want to enter the entire number, please enter only the last 4 digits and call your travel agent by phone to communicate the entire number. DO NOT EMAIL YOUR CREDIT CARD NUMBER. Thank you.

Expiration Date

If no day of the month is displayed on your card place a 01 in this spot

YYYY

CVC Code

This is the 3 digit code located on the back of your card. American Express has a 4 digit code located on the front your card.

Amount of Payment

Electronic Signature

Payment Authorization & Cancellation Terms Acknowledgement

I hereby authorize Becker World Travel to use this information to make any and all payments directly to the supplier for all my approved travel plans. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. I also reviewed all trip details and confirm that all information is correct; any alterations to the trip may result in extra fees. I acknowledge that I am purchasing this trip from a travel agent and not a hotel, airline, or other suppliers directly, therefore, the transaction can’t be canceled due to service dissatisfaction. By typing my name below I acknowledge that I have read and agree to the cancellation terms of all elements of my purchase. I am also responsible for having any up to date passport/ travel documents/visas etc. and I am responsible for any consequences that may arise from not having them. I also understand that I need to check in at least 2 hours before my flights, late check in will result in denial of boarding at my own expense. I understand that I am responsible for keeping track of all payment due dates. I furthermore agree that my submission of this form, via the "Submit" button, shall constitute the execution of this agreement in exactly the same manner as if I had signed, by hand, a paper version of this document.