| Yes! Count me in! | Destination: |
| DEPARTURE DATE: | RETURN DATE: |
| Full Name: (as on passport) | ||
| Address: | ||
| City, State, Zip: | ||
| Phone Number: | ||
| Email: | ||
| Roommate: | ||
| Flight Seat Preference: | ||
| Passions & Interests: | ||
| How did you hear about this trip? |
I am enclosing check number ___________ dated ____________ in the amount of $________ as a _____________ (deposit or full payment) for this Trip.
I hereby authorize Infusions Travel to charge my MasterCard or Visa (circle one) the amount of $____________ for this trip and/or travel services described above and agree not to dispute or chargeback the acknowledged charges.
My credit card number is____________________________________________ Expiration date:_________Sec Code__________
By signing below, I agree to participate in this Trip organized by Patricia Thaxter of Infusions Travel and assume full responsibility of travel as if traveling on my own account. I have read and understand all the details of the Trip. I understand my booking deposit is not refundable, and that high cancellation and change fees apply. Full payment for this Trip is due 65 days before departure date and if I do not pay amount in full when due, I will lose my deposit. Airfares are subject to change by the airlines until ticketed, and it might not be possible for tickets to be refunded, canceled, transferred, or exchanged to a future travel date. Infusions Travel, its partners, affiliates, contractors, suppliers, and employees (“Providers”) shall assume no responsibility or liability in connection with the services being provided. The Providers shall not be responsible for any act, error, omission, injury or any consequences resulting therefrom, whether due to any neglect or any action on the part of the Providers. I understand that if I do not show up on time on the dates of travel, I may relinquish my full payment and travel opportunity.
I am also attaching a legible photocopy of my passport ID page or agree to furnish a copy before ticketing deadline.
| Signature: | ||
| Date: |