Estes Consultant of Travel Client Information Form

Agent: Tammy Estes

Agency: Estes consultant of Travel
Client Information and CC Authorization Form
Contact Information:
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

Area Code Phone Number
Trip Details:

If known at this time: (this may be filled in later)
TRIP BEGIN

Month Day Year
Date
TRIP END

Month Day Year
Date
Name of Supplier (if known)
Booking/Reservation Number (If known)
Passenger Names: (Please List Full Legal Names of All Passengers)
Full names must be listed as they appear on your government issued identification and /or passport for all travelers. If additional space is needed use the space located at the bottom of the form. If you are not sure what identification you will need for your trip consult with your travel agent now.
Please include the information of the person completing the form, if that person is traveling.
Name all passengers (including yourself) traveling starting with Number of Passenger (ie. 1, 2, 3) Last Name, First Name, Middle Initial, Date of Birth. Any missing info and we cannot complete the request. ALL PASSENGERS MUST BE LISTED HERE.
Birth certificates are only required in certain circumstances. If a child under 16 is traveling with you, you can choose other if you are traveling Domestically or Birth certificate and/or Passport if you are traveling Internationally. If you are NOT SURE what id you need please contact me now. This will vary based on method of travel.
Passenger 1 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 2 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 3 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 4 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 5 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 6 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 7 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers License
Passenger 8 will use:

Passport Passport Card Official copy of Birth Certificate* Drivers LIcense
FOR GROUP ONLY: If passenger list is not known due to a group please send additional email as soon as you have the passenger information/list. I agree to do this: (if no then we cannot help you)
An actual Passport is needed should an emergency occur and passengers need to fly home from a foreign port or country.

* A certified copy of a birth certificate is only acceptable for most "closed loop" cruises, (departing from and returning to the same US port.) Please check with your travel agent for all entry and exit requirements for your destination well in advance. This also includes Visa information.
All names and dates of birth listed above are as they appear on the respective government issued identification for each named person *

I agree
Travel Insurance:
I have been advised of the option to purchase travel insurance. This area must be completed by and for each passenger traveling including you. *

I agree and understand that my investment is at risk if insurance is not purchased.
Passenger 1 Insurance Coverage *

Accept Decline
Passenger 2 Insurance Coverage (if applicable)

Accept Decline
Passenger 3 Insurance Coverage (if applicable)

Accept Decline
Passenger 4 Insurance Coverage (if applicable)

Accept Decline
Passenger 5 Insurance Coverage (if applicable)

Accept Decline
Passenger 6 Insurance Coverage (if applicable)

Accept Decline
Passenger 7 Insurance Coverage (if applicable)

Accept Decline
Passenger 8 Insurance Coverage (if applicable)

Accept Decline
This is a group and insurance will be needed for the entire group:
Passports/Visas:
I have been advised of passport/visa requirements related to my trip *

I agree
Change/Cancellation:
I have been advised of potential change/cancellation charges that may be implemented by the supplier in the event that I choose to cancel or change my booking after making the initial deposit. I understand that Estes Consultant of Travel has their own cancellation policies regarding and that separate fees are incurred. My travel agent has explained this to me as well as any alternative advice to cancellations and changes. *

I agree
Please use this area to include any special needs (wheelchair, hearing loss, diabetic or food allergies, etc) or any other additional info you wish to share with me and/or the supplier to make your trip a special one.
Credit Card Information: Form is sent via a secure connection and only accessible by Estes Consultant of Travel. However to remain PCI complaint we can only collect the last 4 digits to be stored on this form or we can be charged heavy fines. This is for your safety as well as ours. Please email the 1st 12 digits in one email and the CV code from the back of card in a separate email both with subject lines "my trip detail" to tammy.estes@estestravel.com. This will be kept separate from the last 4 digits initially entered. Credit Card information is NOT kept on file at our office for security purposes unless you specifically request us to.
Payment Options: *
drop down options
Pay this amount: $
Enter the amount you wish to pay if you known
Cardholder Name *
Credit Card Type *
Card Holder Authorization

I, the above-named authorized credit card user, give Estes Consultant of Travel. and its representative express authorization to charge my credit / debit 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 charges in expressed writing as well as any and all collection and legal fees (if required). This credit/debit card is authorized for only the charges I approve in advance in writing. 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 and require your written approval to proceed in advance of charges incurred.

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 Estes Consultant of Travel.

https://www.transportation.gov/airconsumer/
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 *

Clear
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 or as you so declare in writing.
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