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) *
This payment is for: *
Billing Party's Name (as it appears on card) *
Amount Authorized to Charge (one time charge)* *
Credit Card type *
Credit Card Number (separate numbers with dashes) *
Expiration Date (mm/yyyy) *
CCV (Security Code on back of card) *
Billing Address (including city state and zip) *
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 *
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