cc auth

Jewish Travel Agency, division of EMCO Travel

4172 Ridgemoor Dr. N, Palm Harbor, FL 34685 | 727-254-4373 | info@sophiastravel.com

I, the undersigned (Print Name), Authorize EMCO Travel to charge my credit card representing payment for booking number (if available)

Print Name
[text* your-name]

Booking Number (if available)
[text booking-number]

Include Services:
[textarea services x2]

To charge the amount:
[text* charge-amount placeholder “$”]

To My:
[select* menu-39 “Select Card” “Visa” “Mastercard” “AMEX” “Discover”]

Credit Card Number:
[text* card-number]

CVC Code:
[text* cvc size:4]

Expiration Date:
[date* expire]

Billing Address:
[text* bill-address]

City:
[text* city]

State/Province
[text* state]

ZIP Code:
[text* zip]

Country:
[text* country]

E-mail:
[text* email]

Please Confirm E-mail:
[confirm_email* confirm_email-803]

Phone:
[text* phone]

[acceptance acceptance-713 optional] I am aware of any cancellation policies and agree not to dispute or attempt of Chargeback any of the above signed for and acknowledged charges. [/acceptance]