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Credit Card Credit Card Authorization Form
For security reasons we have established this secure form of payment. Please , print, fill , sign, and fax this form to +(506) 290-2853 ( this is a C.R. # )
The following form must be filled out completely for us to accept Visa / Master
(Cardholder's name as it appears on the credit card)
to charge $_______ on my VISA / MASTER credit card # __________________
Exp. Date ______________Issuing Bank ________________________________
Passport #_______________ Date of birth ________
Mother's maiden name ________________________
Address____________________________________________________________
Billing Address (if different) ___________________________ ____ ____________
Daytime phone #__________ _ __ Fax #: _ ___________ E-mail _______________
Address:_____________________________________________________________
I have read and accept the conditions specified in our MAIN COMPANY's Terms & Conditions page and I agree to pay the amount here authorized, even though I have not signed the original charge note or voucher , amking this transaction a Credit Card NOT PRESENT type . I agree to pay this amount in case of "No Show". I understand that, in case of cancellation, I am responsible for all penalties charged by individual suppliers plus the ones specified by our main office Costa Rica Travelsite & CRT Rent a Car .
Photocopy of Credit Card (front and back)
Credit Card Holder's Signature:_____________________________ Date:______
San Jose, Costa Rica
Telephone: (506) 22290-2878 / Fax: (506) 2290-2853