Testing Form Page Credit Authorization This form authorizes your Mickey Adventures agent to process payments and credit card holds for your vacation on your behalf. Please read the form carefully and complete all information. IMPORTANT NOTE: Please do NOT include your entire credit card number on this form. You will provide that to your agent by phone or in person.Mickey Adventures Travel Agent*Jen ZinnoPatty HurleyAmy LandrusMissy LoganLang MastroDanielle NettaErin TietjenAndrew SmithCredit Card Type*VisaMastercardAmerican ExpressDiscoverOtherLast 4 digits of credit card number* Expiration Date* Credit Card Expiration DateCardholder Name (as it appears on the card)* Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* I hereby authorize my Mickey Adventures agent to use my credit card listed above for the following purpose (check all that apply): Vacation Deposit Final payment on my vacation Credit card holds for dining and other reservations Prepayment of any dining or other reservations Travel insurance payment Any other components of my vacation not listed above Deposit Amount*I certify that I am the cardholder above.* Yes No I authorize Mickey Adventures to process payments on my behalf using my credit card.* Yes No I certify that I will authorize specific charge amounts by sending an email to my Mickey Adventures agent prior to payment.* Yes No Signature* By signing my first and last name in the box, I certify that I agree to conduct this transaction by electronic means. I also certify that I am responsible for payment of all charges listed above and will hold Mickey Adventures and its agents harmless with respect to those payments, and any other payments Mickey Adventures processes on my behalf. NameThis field is for validation purposes and should be left unchanged.