*** 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) Cash-Back Voucher 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: Booking/Reservation#* Destination Date of Travel Passenger Name (s)
Signature Date First Name Last Name