Please sign and complete this form to authorize The Curated Travel Collection to make a one-time debit to your credit card listed below.

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Client Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Birthdate * +

Names and birthdates of traveling party: *

Payment Information

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV code *

Amount to be charged *

Date of payment * +

Description of Goods and Services *

Name of my Curated Travel Collection advisor *

Credit Card Authorization *

I authorize the above-named agent with The Curated Travel Collection to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Terms & Conditions *

I have read and agree to The Curated Travel Collection LLC's Terms and Conditions.

Future Transactions *

I understand that my credit card information will be saved to file for future transactions on my account.

This credit card may also be used for additional payments for the items marked below, but only when written instruction to use the "card on file" for payment is given. Please check all that you wish to authorize. *

If you are traveling to Walt Disney World or Disneyland, please add your credit card information to your “My Disney Experience” account profile for Advance Dining Reservation bookings. The costs for these reservations will vary and you will be notified of the price before making any such reservation. These reservations can be seen in your My Disney Experience account after they are booked. Make sure to check your reservations in your account and make any changes or cancellations at least 2 hours in advance (for most dining reservations) to avoid unnecessary credit card charges.

Travel Insurance *

I would like to insure my trip! Please send me a no-obligation quote.

I have my own travel insurance.

I DECLINE travel insurance. I understand that by declining to purchase travel insurance, if I cancel or interrupt my trip for any reason, portions or the entirety of the travel arrangements may not be refundable; I am solely responsible for any cancellation penalties/out-of-pocket expenses (including medical expenses) that I may have incurred during the course of my trip.

Signature *

clear

Date * +