*** Polmart Travel - Credit Card Authorization ***

Fields with * are required to submit form. Click "Submit Secure Form" button on the bottom
to save data. After successful submission you will see "Print Form" button, that will allow you to print this page

I *, do hereby authorize Polmart Unlimited, Inc. to charge my
credit card number *, exp. *, security code *,
in the amount of $ *. I have read and agree with the terms and conditions
attached to my reservation including cancellation penalty  (initial).

INSURANCE (click for details)
 No Insurance

My billing address and phone number, e-mail are as follows:
1) Billing address*  
2) Phone number*  
3) Email address*

 My booking information is as follows:
Date of Travel
Passenger Name (s)

Signature  Date  
First Name  Last Name