EXISTING CLIENT FORM

Payment Authorization

Use this form only after Breanna has provided the reservation details and amount to authorize.

Security notice: Do not enter your full credit card number or CVV on this form. Enter only the last four digits. Breanna will obtain any additional payment information through an appropriate secure method.

Reservation Information

Guest / traveler name Trip type Supplier name Confirmation number Departure date Return date

Blevins Travel contact

Cardholder Information

Name exactly as it appears on credit card

Last four digits only Expiration date

Billing address

CityStateZIP code

Daytime phone Email address

Payment Authorization

Total amount authorized to charge

By entering my name below and submitting this form, I authorize the charge listed above for the travel reservation described on this form.

Authorization name Date

Travel Protection

Travel protection was offered Travel protection was accepted

If travel protection is declined, the traveler may not be covered for changes or cancellations and may be responsible for applicable penalties and out-of-pocket expenses.

Cardholder Acknowledgment

I certify that I am the authorized cardholder and the information provided is accurate. I authorize Blevins Travel to use the payment information I separately provide to process the approved travel charge with the applicable travel supplier.

I agree to the acknowledgment above.

Cardholder printed name Date

Blevins Travel is an Independent Travel Agent of Archer Travel Service, Inc. Seller of Travel: FL 35395 | CST 2001330-10 | HI TAR-6612 | WA 603352551