Caldwell Travel

Credit Card Charge
Irrevocable promise of payment, charge statement

Date ____/____/_____

Customer:	_________________________________________________________
Address:	_________________________________________________________
	_________________________________________________________

I authorize Caldwell Travel to charge my   DS  AX   MC  VI

Cc# _____________________________________________ exp. Date: ____/_______

Up to the total amount of (US Dollars): $________________

I agree to pay the total amount according to the terms and conditions of Caldwell Travel which I have received, read and accepted in full with no exceptions. I am also responsible for all legal fees necessary for collection of the above amount.

X__________________________ (Signature)

Cardholder acknowledges receipt of goods and/or services in the amount of the total shown hereon agrees to perform the obligations set forth by the Cardholder’s agreement with the issuer.

PLEASE FAX THE COMPLETED FORM ALONG WITH COPY OF FRONT AND BACK OF CREDIT CARD TO: 317-885-9873.
ANY QUESTIONS CALL 317-885-9855. THANK YOU!