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Credit Card Authorization Form

First name*

Last name*

Phone*

Email*

Card Type ( Visa, Mastercard, Amex etc)*

Card Number*

Expiration Date*

CVV*

Street Address to match card *

City to match card*

State to match card*

Zip Code to match card**

Purpose of payment *

Amount you want charged today*

Todays Date*

Month

Day

Year

I authorize Leneus Leisures, to charge this card, the amount listed today. Leneus Leisures Travel Agency agrees to charge only the amount explicitly authorized by the client as listed on this form.

leneusleisures@gmail.com

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