Epic Travel Atlanta Payment form



This form has been created in order to allow you to charge to your credit card for a travel booking that has been made by Epic Travel Atlanta. Please provide all the information requested below to ensure prompt processing of your payment.

Name:
  * Required


Email:
  * Required


Trip and Travel Date:
  * Required


Card Information:

Type of Card:


Name on Card:


Card Number:


Expiration Date:


Code on the back or front of card:


Amount:


Billing Address
If different from mailing Address:


City, State, Zip:


Home Phone:


I certify that all information is complete and accurate. I hereby authorize Epic Travel Atlanta to collect payment for all charges as indicated above on this form by processing a charge to the credit card listed above. Charges must not exceed the amount listed above. I understand that a new form will have to be completed if another payment needs to be made. I certify that I am the authorized signer of the credit card.






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