Who is your Travel Agent
Your Confirmation Number:
Please use your confirmation number,
the invoice number.
Your Name(s) *:
Your Email *:
Is this a Honeymoon Registry Gift?
If so, please provide the couple's name(s):
Credit Card Type *:
Credit Card Type
Payment Type *:
Other OR Final Payment
Honeymoon Registry Gift
Amount to charge * :
Travel Protection *:
I understand that I CANNOT purchase the cancel for any reason insurance once my deposit is paid.
Additional Comments :
By submitting, you certify that you are the cardholder and are authorizing the travel agency or its chosen Tour Operator/Supplier/Cruise Line to charge the listed amount to the credit card. You certify that you have verified that all information contained in the confirmation you received is accurate. You also certify you have read the Terms & Conditions and the appropriate Travel Protection Plan details. Cancellation penalties may apply. Insurance is not refundable. This charge will be manually applied by the agency to your reservation. If there are any issues, an agent will get back to you. Please note that you may not see a charge from the travel agency on your credit card statement; the charge will come from our supplier and/or the airline directly. Payment may take 3-5 business days to fully process and be reflected on your statement.
I authorize the travel agency to use the above information to charge my credit card the stated amount. Completion of this form and the initialing of this box signifies acceptance in lieu of my signature.
POLKA DOTS N' WISHES TRAVEL AND ITS INDEPENDENT CONTRACTORS (HEREIN “TRAVEL AGENCY”) ARE ACTING AS A MERE AGENT FOR SUPPLIERS (IDENTIFIED ON THE ACCOMPANYING DOCUMENTS) IN SELLING TRAVEL-RELATED ACCEPTING SERVICES, OR IN ACCEPTING RESERVATIONS OR BOOKINGS FOR SERVICES THAT ARE NOT DIRECTLY SUPPLIED BY THIS TRAVEL AGENCY (SUCH AS AIR AND GROUND TRANSPORTATION, HOTEL ACCOMMODATIONS, MEALS, TOURS, CRUISES, ETC.) TRAVEL AGENCY, THEREFORE, SHALL NOT BE RESPONSIBLE FOR BREACH OF CONTRACT, FAILURE TO COMPLY WITH ANY LAWS SUCH AS THE AMERICANS WITH DISABILITIES ACT (ADA), OR ANY INTENTIONAL OR NEGLIGENT ACTIONS OR OMISSIONS ON THE PART OF SUCH SUPPLIERS, WHICH RESULT IN ANY LOSS, DAMAGE, DELAY, INCONVENIENCE OR INJURY TO TRAVELERS OR TRAVELERS COMPANIONS OR GROUP MEMBERS. UNLESS THE TERM “GUARANTEED” IS SPECIFICALLY STATED IN WRITING ON YOUR TICKETS, INVOICE, OR RESERVATION ITINERARY, TRAVEL AGENCY DOES NOT GUARANTEE ANY OF SUCH SUPPLIER’S RATES, BOOKINGS, RESERVATIONS, CONNECTIONS, SCHEDULING, OR HANDLING OF BAGGAGE OR OTHER PERSONAL EFFECTS. TRAVEL AGENCY SHALL NOT BE RESPONSIBLE FOR ANY INJURIES, DAMAGES, OR LOSSES CAUSED TO ANY TRAVELER IN CONNECTION WITH TERRORIST ACTIVITIES, SOCIAL OR LABOR UNREST, MECHANICAL OR CONSTRUCTION FAILURES OR DIFFICULTIES, DISEASES, LOCAL LAWS, CLIMATIC CONDITIONS, ABNORMAL CONDITIONS OR DEVELOPMENTS, OR ANY OTHER ACTIONS, OMISSIONS, OR CONDITIONS OUTSIDE THE TRAVEL AGENTS CONTROL. TRAVELER ASSUMES COMPLETE AND FULL RESPONSIBILITY FOR, AND HEREBY RELEASES THE AGENCY FROM, ANY DUTY OF CHECKING AND VERIFYING ANY AND ALL PASSPORT, VISA, VACCINATION, OR OTHER ENTRY REQUIREMENTS OF EACH DESTINATION, AND ALL SAFETY AND SECURITY CONDITIONS OF SUCH DESTINATIONS, DURING THE LENGTH OF THE PROPOSED TRAVEL. HOWEVER, WE SPECIFICALLY RECOMMEND THAT U. S. CITIZENS TRAVELING TO CANADA, MEXICO, OR THE CARIBBEAN, DO SO WITH A VALID U. S. PASSPORT. FOR INFORMATION CONCERNING POSSIBLE DANGERS AT INTERNATIONAL DESTINATIONS, CONTACT THE TRAVEL ADVISORY SECTION OF THE U. S. STATE DEPARTMENT, (202) 647-5225, OR ACCESS THE STATE DEPARTMENT’S ON-LINE TRAVEL ADVISORY SERVICE WWW.STATE.GOV. FOR MEDICAL INFORMATION, CALL THE U. S. CENTERS FOR DISEASE CONTROL (CDC), (404) 332-4559 OR LOG ON TO http://wwwnc.cdc.gov/travel. BY EMBARKING UPON HIS/HER TRAVEL, THE TRAVELER VOLUNTARILY ASSUMES ALL RISKS INVOLVED IN SUCH TRAVEL, WHETHER EXPECTED OR UNEXPECTED. TRAVELER IS HEREBY WARNED OF THE ABOVE RISKS AS WELL AS TRAVEL INDUSTRY BANKRUPTCIES AND MEDICAL AND CLIMATIC DISRUPTIONS, AND THE POSSIBILITY TRAVELER MAY BE UNABLE TO TRAVEL AS SCHEDULED BECAUSE OF PERSONAL EMERGENCY. TRAVELER IS ADVISED TO OBTAIN APPROPRIATE INSURANCE COVERAGE AGAINST THESE RISKS; INFORMATION IS AVAILABLE THROUGH THIS TRAVEL AGENCY REGARDING TRAVEL INSURANCE. TRAVELER’S RETENTION OF TICKETS, RESERVATIONS, OR BOOKINGS AFTER ISSUANCE SHALL CONSTITUTE A CONSENT TO THE ABOVE AND AN AGREEMENT ON HIS/HER PART TO CONVEY THE CONTENTS HERETO TO HIS/HER TRAVEL COMPANIONS OR GROUP MEMBERS
By checking the box below and adding your signature, you indicate that the above amount is correct, you authorize the travel agency to charge your credit card for the specified amount, and you agree to the terms and conditions.
Electronic Signature: (Sign with mouse or touch)*