Exceptional Services Group

Exceptional Services Group

9070 Kimberly Blvd., Suite 50, Boca Raton, FL 33434

(561) 852-0910 voice ~ (561) 852-0960 fax

Credit Card Charge Authorization

Please fax back completed form to (561) 852-0960.

________________________________________________________________________

___Visa ___MasterCard ___Discover ___American Express

Traveler Name(s): _______________________________________________________

________________________________________________________________________

Description of charge/s: ____________________________________________________

Amount: ________________________

Trip: _____________________ Dates: _____________________

Name as it appears on card _________________________________________________

Billing Address for card ____________________________________________________

CC# __________________________________ Exp. Date ___________ CSC# _______

Passenger’s Home Address _________________________________________________

Phone __________________________________________________________________

The issuer of the credit card identified on this form is authorized to pay the amount shown as Total upon proper presentation. I promise to pay TOTAL (together with any other charges due thereon) subject to and in accordance with the agreement governing the use of such card. I hereby authorize Exceptional Vacations to charge my card for vacation payments for myself and/or my travel party. I understand in the event of cancellation, penalties may be accessed. I understand the terms and conditions of the authorization and agree to indemnify and hold Exceptional Vacations harmless from and against all liabilities, losses, charges, costs and expenses incurred by Exceptional Vacations as a result of any credit card charge back received in connection with the aforementioned client.

_________________________________________ ___________________

Signature of Card Holder Date

Exceptional Vacations is registered with the State of Florida as a Seller of Travel. Registration No. ST35704. Exceptional Vacations is a division of Exceptional Services Group, L.L.C.