Simply World Class
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Simply World Class Travel Booking Inquiry Form
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DEBIT/CREDIT CARD AUTHORIZATION FORM - GO PRT
By submitting this form, you authorize Perfect Reflections Travel, LLC to debit/charge your card for travel services and you agree to the terms and conditions of the Supplier who will be providing your travel services.
Your signature is required to complete your travel plans. Please read the cancellation/change penalties that may apply to changes or cancellations of your travel.
PLEASE NOTE AS OF OCTOBER 12, 2018:
Effective immediately -- a monthly debit/credit card authorization form is required for Perfect Reflections Travel to process your monthly payments. This requirement to complete a form monthly will help to avoid confusion and relieve any issues just in case you may need to switch cards, inform us of any changes, or your monthly payment amount differs from the previous month(s). Please submit on or before the 23rd of every month to avoid late fees and/or penalties. Thank you.
Payment for Travel Services - Electronic Signature
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I Authorize my Debit/Credit Card to be Charged.
I, the debit/credit card holder, authorize Web Star Travel to debit/charge my debit/credit card account for my travel services. By checking this box and submitting this form, I agree to the terms and conditions of the Supplier who will be providing my travel services. Click button if you agree.
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Indicates required field
PRT Agent/ Simply World Class/Referral Source
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- Select One -
Kim Woodruff / Simply World Class
Toni Porter / Perfect Reflections Travel
Other - List in Comment Section
Trip or Event Name
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Event/Trip Name:
2019 Soul Beach Music Festival - Aruba
Your Hotel/Resort Choice
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Resort 1: Hotel RIU Palace Antillas Aruba (AI)
Room Category - Hotel RIU Palace Antillas Aruba (AI)
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4 Nights - Junior Ste Sea View DOUBLE
5 Nights - Junior Ste Sea View DOUBLE
4 Nights - Junior Ste View SINGLE (at current rate)
5 Nights - Junior Ste View SINGLE (at current rate)
See full details on website or Facebook event page for description and cost of travel packages.
Please check which amount of nights and room category you prefer for Soul Beach Music Festival Aruba 2019.
Do you plan to share a room?
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YES
NO
Roommate's Name(s)
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If you are sharing a room, ONLY list the names of those who will be rooming with you.
Bed Size Preference
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1-KING
2-QUEENS
TRAVELERS NAME(S):
Payment for which Individual(s) or Group Trip?
(List all full names on separate lines & as shown on passport)
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Please list full names of ALL who are registering to attend SBMF 2019 and ONLY those who you are paying for.
Please verify all legal names and list each individual's full name on a separate line and AS EXACTLY SHOWN ON THE PASSPORT.
Example:
Jane Marie Smith or Jane M. Smith
George Lee Smith or George L. Smith
Dates of Travel
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(MM/DD/YY)
Example: 05/22/19 - 05/27/19 (actual 5-nights)
05/23/19 - 05/27/19 (actual 4-nights)
05/20/19 - 05/29/19 (actual 4/5 + extra nights)
Do you want to include travel insurance as an add-on option to your total package cost (per person)?
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YES -- I hereby ACCEPT travel insurance coverage. I understand the trip cancellations and interruption details, terms and conditions that were provided or discussed with me.
NO -- I hereby DECLINE travel insurance coverage. I understand the trip cancellation and interruption details, terms and conditions that were provided or discussed with me.
Travel Insurance: Please indicate if you wish to YES (Accept) the travel insurance offered or you choose NO (Decline) to not take the insurance. Please note you WILL NOT be allowed to ADD it later. You will be required to obtain travel insurance on your own.
It is strongly recommended to purchase travel insurance. If you choose not to purchase travel or cancellation insurance, you understand you are liable for any cancellation penalties and out-of pocket expenses incurred. You will also make your own provisions in the event of an emergency while traveling.
For travelers who ACCEPT, this will be an add-on option and you must pay the travel insurance cost upfront during the initial booking. (Example: If the cost for insurance for you is $78, then you must pay the $200 initial deposit + $78 insurance = $278 for deposit.)
Do you wish to set up a flexible payment plan for this trip?
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YES (As stated in Simply World Class' SBMF 2019 event details)
NO
Payment Plan: Please indicate YES or NO if you are looking to be on a flexible payment plan.
Total For The Trip ($)
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Amount Authorized
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Please note $$$ amount you are authorizing for initial deposit per person AND monthly payment per person
EXAMPLE:
(A) $200 initial deposit and $200 monthly per person + final balance due 03/23/19.
(B) $500 initial deposit and $200 monthly per person + final balance due 03/23/19.
(C) Full payment (indicated $$$ amount)
Traveler Information
Please complete this form as accurate as possible. If a question does not apply to you, please leave blank.
Credit/Debit Card Type
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Visa
Mastercard
American Express
Discover
Choose One. All Major Credit and Debit Cards Accepted. NO Holds, NO Exceptions.
Card Number (no dashes/hyphens)
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Please provide full and correct debit or credit number. DO NOT INCLUDE DASHES OR HYPHENS ( - )
Expiration Date (mm/yy)
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2-digit mm/yy (i.e. 01/23 or 10/22)
Card Security Code/CVC #
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The CVV code is either the three digits on the back of your card for Visa, MasterCard and Discover or the four digits on the front of your American Express card that you'll find after your account number.
Name as it appears on your card
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First
Last
Put First Name and Middle Name or Initial in the first box as it appears on your card. Please put a space (i.e. Jane Marie OR Jane M) and Last Name ONLY in second box.
Middle Name or Initial (If Applicable)
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Middle name or initial, if applicable, and appears on your card.
Billing Address
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Line 1
Line 2
City
State
Zip Code
Country
Complete with address that is associated with the debit or credit card you are authorizing and using to make payment.
For STATE you can note PROVINCE here if your country is not USA.
(If your Mailing Address is Different, please provide in the "Amount Authorized/Payment Plan/Comment" section below.)
Phone Number
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Complete with phone number that is associated with the debit or credit card you are authorizing and using to make payment.
Work Phone Number
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E-Mail Address
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Special Requests & Comments
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SPECIAL REQUESTS & COMMENTS:
Indicate here any special requests, instructions, dietary restrictions, etc. we need to be aware.
Please note there are certain requests we cannot guarantee (i.e. room assignments, location of room/floor level other than what has been paid for, near elevators or a friend, etc.)
EXAMPLES:
- Dietary restrictions (vegan, vegetarian, gluten-free, etc.)
- Special accessibility, handicap-accessible room required, etc.
- Please NO ground level room
- Please hypo-allergenic/feather-free room
- Please assign me a room close to or near Jane Marie Smith.
- Please assign me a room close to the pool or beach.
Electronic Signature (Type Full Name)
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Please electronically sign with full name for submission.
EXAMPLE:
Jane M Smith OR
Jane Marie Smith
Today's Date
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Please electronically sign with today's date for submission. (MM/DD/YYYY)
Submit
Note
: Fields marked with
*
are required
