Please sign and complete this form to authorize Ears of Experience/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 field. 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 *

Payment Information

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV Code (3 digit number on back of card) *

Amount to be charged *

Date of payment * +

Description of goods and services *

Name of my Ears of Experience/Curated Travel Collection Agent *

Credit Card Authorization *

I authorize the above-named agent with Ears of Experience/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.

Future Transactions *

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

Please sign and complete this form to authorize Ears of Experience/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. *

clear