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Credit Card Payment Order

    Tour or Group Name

    Dates of Tour

    Name on Card

    Payment Method

    VisaMC

    Card Number

    Exp. Date

    /

    Security Code

    (The last 3 digits on the back of the card)

    Amount to be charged

     

    PASSPORT INFORMATION

    1st Passenger:

    First Name: Middle Name: Last Name:

    Passport Expiration Date

    /

    Birth Date (MM/DD/YY)

    / /

    Passport Number

    Nationality

    Gender

    MaleFemale

    E-Mail Address

     

    2nd Passenger:

     

    First Name: Middle Name: Last Name:

    Passport Expiration Date

    /

    Birth Date (MM/DD/YY)

    / /

    Passport Number

    Nationality

    Gender

    MaleFemale

    E-Mail Address

    * If you have 3rd, 4th or more passengers on your party, you can email the passport information of the additional participants to info@travelrefinery.com

    Telephone Number

    Billing Address

    Special Notes