Please fill in this form completely before printing this page.

     In lieu of my credit card imprint, I, , hereby
                                                                     (Print complete name of cardholder)
authorize thru Travel with Grace, Inc., to charge  

my account no.:  exp. date/

the total amount of USD$  for the purchase of tickets of:

Name of passengers 

(please fill in complete names as how they appear on passport/s):    

    1)         

    2)         

    3)   

    4)

    5)

 

 

You may use this space for additional names or any additional information/remarks:

    My Billing Address:    

    No. and Street Name   Apt./Ste. No.

    City      State/Province

    Zip Code                          Country

 

Home Tel. #               Work Tel. #

Cell/Mobile/Other #    Email Address:
 

By signing below, I acknowledge full responsibility for payments of the above mentioned amount in accordance with my credit card membership agreement.  I fully understand that I'm purchasing a highly restricted ticket/s and that cancellations/changes are subject to penalties/fees.
 

    ____________________________                                       _______________________
                         (Signature)                                                                                   (Date)

 IMPORTANT:   Please attach a photocopy of your credit card (FRONT AND BACK) at it's lightest setting, and an identification that show's your signature (example: driver's license, passport etc.) to verify proof of ownership of the above account no.  Upon completion, please fax to 1-917-591-3329 or email to sales@travelwithgrace.net this form along with the required attachments.  We reserve the right to refuse the transaction if this requirement is not completed accurately and in timely manner.

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