Janelle & Co. Travel LLC

Agent Name: Nicole Baniak

Contact Information:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Date of Departure*

MonthDayYear

Date of Return*

MonthDayYear

Reservation Number (If known)

Guest Names:

Please include the information of the person completing the form, if that person is traveling.

Guest 1*

First NameLast Name

Birthdate*

MonthDayYear

Guest 2

First NameLast Name

Birthdate

MonthDayYear

Guest 3

First NameLast Name

Birthdate

MonthDayYear

Guest 4

First NameLast Name

Birthdate

MonthDayYear

Guest 5

First NameLast Name

Birthdate

MonthDayYear

Change/Cancellation:

I have been advised that these charges are nonrefundable in the event that I choose to cancel or change my booking after making the payment.*

I agree

Amount Approved

Card Holder Authorization

I, the above-named authorized credit card user, give Janelle & Co. Travel LLC. and its representative express authorization to charge my credit card for the purposes detailed above. I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all agreed upon (as stated above) charges as well as any and all collection and legal fees. This credit card is authorized for only the charges noted above. By signing this "Credit Card Authorization" form, I/my organization acknowledge receipt and understanding of its contents, including its "Explicit Authorization" clause.

Disclosure and Consent

We make every effort to honor the package price quoted originally, however; under certain circumstances your price may be subject to increase prior to full payment due to an increase in the cost for one or more of the travel components of your package. We will always notify you in such an event.

Prices will not increase after you make full payment, except for charges resulting from increases in government-imposed taxes or fees.

By signing below, you expressly acknowledge your acceptance of these conditions applicable to your purchase and by signing your name and initials you have read and agreed to this being your signature by electronic transfer to Janelle & Co Travel LLC.

http://airconsumer.dot.gov/rules/EAPP_2_FAQ_01-11-2012final.pdf

By signing below, I agree to the accuracy of the information disclosed within this form and to the authorization to charge my credit card for the amount specified above.

Signature*

Additional Comments or Passenger Information

Enter the message as it's shown*

Note: Your card will not automatically be charged by completing and submitting this form; however, completing and submitting this form does give the agent the right to charge the card for the amount and purpose authorized above.

Ticket Only Client Information Form

Card Holder Authorization

Thank you for your business!