EmailMe Form - Credit / Debit Card Authorization Form

Credit Card Authorization Form
This form collects data according to PCI DSS. All information will remain confidential.
Client Name
Prefix First Middle Last Suffix
Name (as it appears on card)
Prefix First Middle Last Suffix
Credit Card

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Payment Amount
$ Dollars . Cents
Indicate the amount that you authorize to be charged to your card each month
Future Payment Start Date
MM / DD / YYYY
Indicate the date you authorize your Future Payments to begin
Email for receipt of Confirmations
You will receive an email with a confirmation for each payment made
FUTURE PAYMENT AUTHORIZATION (only select one option)
I certify that all information listed above is complete and accurate.
I hereby authorize Fly Today Travel Agency to charge my credit card as detailed on this form.
Signature
Clear
Use your mouse to sign the form. Your signature constitutes your acceptance of the Terms and Conditions and the Fees outlined in this form