233 East Erie Street, Chicago, IL 60611

Credit Card Billing Authorization Form
Please download this form, complete the form, type or print clearly,
attach photocopies of front and back of Credit Card, Drivers License and
fax to: 312.475.0657

In lieu of my Credit Card imprint, I ______________________________________hereby authorize / have

authorized Exotic Journeys / airlines to charge my credit card for the services ordered in the amount of

$ ___________________ Amount in words __________________________________________________

Credit Card Information (circle one): American Express / Visa / Master Card / Discover

Credit Card Number: ____________________________________________________________________

Date of Expiry: ________________________ Security Number: ____________________

Credit Card Billing Address: ______________________________________________________________

City: ________________________________________________ State: ________ Zip: _______________

Phone (Home): _____________________________________ Fax (Home): ________________________

Phone Number (Cell): ___________________________________________________________________

e-mail: _______________________________________________________________________________

Companion/s - Authorized by Card Holder: ______________________________________________________

By signing below, I agree to pay in full or in extended payments when billed in accordance with standards of
issuing credit card bank / company. I acknowledge that I have read and understand the terms, conditions and
cancellations charges of airlines, overseas operators and Exotic Journeys Inc. I understand that airlines, rail,
event, monument entrance tickets and some tour arrangements are non-refundable under any circumstances
and or have cancellation fees / charges. I agree that any refund claims and / or discrepancies, if any, on non
delivered services will be settled directly with airlines, service providers, Exotic Journeys and that I waive and
relinquish any and all rights to dispute the above charged amount with the credit card bank / company resulting
in charge back. I have attached legible copies of my driver license / passport and credit cards as means of legal identifications.

Signature: ____________________________________ Date Signed: ________________________

 

(for office use - please DO NOT write below)

Signed Form Received on:_______________ By____________ Date: ________________

Approval Code: _____________Date: ______________Invoice No.: __________________