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Credit Card Authorization Form
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baleariacaribbeanreceiving@gmail.com
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* Indicates required question
Email
*
Your email
Name on your Credit Card
*
Your answer
Type of Card:
*
VISA
MASTER CARD
AMEX
DISCOVER
OTHER
Required
Credit Card Number
*
Your answer
Expiration Date
*
Your answer
Security Code
*
Your answer
Your Billing Address
*
Your answer
Your City, State, ZIP
*
Your answer
Your Phone Number
*
Your answer
Booking Number
*
Your answer
Total Amount
*
Your answer
By Signing this form, you authorize us to charge your card for the amount listed above
*
Typing Your name from your email, you authorize us to charge your card
Your answer
Send me a copy of my responses.
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