Initial Deposit Client Agreement Form

Hazleton, Pennsylvania

info@beaamazedtravel.com

(570) 599-1754

Please complete all required fields and click submit

All information will be held confidential

Cardholder Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone Number *

Traveler Information

Please list all travelers names and birth dates as they appear on their official identificiation (i.e. passport and/or drivers license)

Names and Dates of Birth *

Passport Certification

I certify that everyone in my travel party (listed above in the traveler information box) has a valid passport or will have a valid passport at the time of travel. I also understand that most international destinations require that my passport is valid for an additional six months past the date of my arrival. Based on this information, everyone in my party is elidgible to travel internationally.

Please select one. *

I certify that everyone in my party is eligible to travel internationally.

My trip is within the United States and we won't need passports.

Travel Insurance Certification

Please Read This Carefully!

Now that you have arranged your trip, as a professional travel agent I feel that it is my responsibility to recommend travel insurance to protect your investment. Please read the following bullets carefully in order to make an informed decision concerning this important matter. Please call or messge me with any questions you may have.

AT THE TIME OF FIRST PAYMENT:

◾I have been advised of the cancellation penalties for my purchase.

◾I understand that Travel Insurance can protect me from possible loss of money due to supplier bankruptcy/default, unexpected trip cancellation/interruption due to accident, sickness or death, baggage loss, medical expenses and emergency air transportation cost.

◾I understand that I must purchase Travel Insurance immediately to obtain maximum coverage.

◾I understand that I will be charged for any vendor cancellation fees and an additional agency fee of $50 per person in the event of cancellation if I do not purchase travel insurance.

At this time I wish to: *

Purchase the recommended travel insurance.

Decline the recommended travel insurance.

Payment Authorization

Credit Card Type *

Name on Card *

Credit Card Number *

Expiration Date *

CVV *

Amount of Payment *

I hereby authorize Bea Amazed Travel to debit my credit card in the amount authorized above by me for the approved trip plans. I further certify that the information I have provided in the passport certification and travel insurance certification sections are true and correct.

Signature *

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