House Music Cruise Credit Card Authorization Form
Please fill out this form to authorize HMC to make cruise payments with the credit card information entered below. All payments are non refundable. However, cruise spots may be sold for a $100 name change fee.
Date (mm/dd/yyyy) *
Your answer
This payment is for: *
Your answer
Billing Party's Name (as it appears on card) *
Your answer
Amount Authorized to Charge (one time charge)* *
Your answer
Credit Card type *
Credit Card Number (separate numbers with dashes) *
Your answer
Expiration Date (mm/yyyy) *
Your answer
CCV (Security Code on back of card) *
Your answer
Billing Address (including city state and zip) *
Your answer
I authorize House Music Cruise to charge my credit card for agreed upon purchases as stated on this form. I agree to pay for this purchase in accordance with the issuing bankcard holder agreement. *
Electronic Signature and Date *
Your answer
Notes:
Your answer
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