Fleurimond/Clergeau Event Payment Form

Group/Event Name or Code (if applicable):

Name of event you're planning to attend.

Contact Information:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Area CodePhone Number

Date of Departure*

MonthDayYear

Date of Return*

MonthDayYear

Room Type/Description

Your room selection. This may be with your rate information.

Booking/Reservation Number (If known)

Guest Names: (Please List Full Legal Names of All Passengers)

Full names must be listed as they appear on your government issued identification and passport for all travelers. If additional space is needed use the space located at the bottom of the form.

Please include the information of the person completing the form, if that person is traveling.

Guest 1*

PrefixFirst NameMiddle NameLast Name

Birth Date*

MonthDayYear

Guest 2

PrefixFirst NameMiddle NameLast Name

Birth Date

MonthDayYear

Guest 3

PrefixFirst NameMiddle NameLast Name

Birth Date

MonthDayYear

Guest 4

PrefixFirst NameMiddle NameLast Name

Birth Date

MonthDayYear

An actual Passport is needed should an emergency occur and passengers need to fly home from a foreign port.

* A certified copy of a birth certificate is only acceptable for most "closed loop" cruises, (departing from and returning to the same US port.

All names and dates of birth listed above are as they appear on the respective government issued identification for each named person*

I agree

Travel Insurance:

I have been advised of the option to purchase travel insurance.*

I agree and understand that my investment is at risk if insurance is not purchased.

Passenger 1 Insurance Coverage*

AcceptDecline

Passenger 2 Insurance Coverage (if applicable)

AcceptDecline

Passenger 3 Insurance Coverage (if applicable)

AcceptDecline

Passenger 4 Insurance Coverage (if applicable)

AcceptDecline

Passports/Visas:

I have been advised of passport/visa requirements related to my trip*

I agree

Air Carriers and Baggage:

I have been advised of the actual airline serving each leg of my flight(s), as well as the corresponding baggage policies. *

I agreeNot Applicable

Please use this area to include any special needs or additional info you wish to share.

Terms and Conditions:
Platinum Key Travel Concierge strives to service, Platinum Key Travel Concierge is associated with one or more travel affiliates. By clicking submit, you certify that you are the card holder and that you authorize Platinum Key Travel Concierge, LLC. or their affiliates to charge your credit card in the amount indicated. You are further advised that the posted charge may be in the name of Platinum Key Travel Concierge, LLC. or one of its affiliates. You may request from Platinum Key Travel Concierge, LLC. the name of the affiliate that will appear on your statement. Please be advised that unless otherwise noted, all quotes and charges processed will be US Currency (USD).

Penalties apply for changes, reductions and/or cancellations. Please check and initial below to accept these Terms & Conditions; and note that by doing so, you are acknowledging the potential penalties and fees that may be incurred for changes, reductions and/or cancellations. Platinum Key Travel Concierge, LLC takes pride in providing our clients all the necessary details to ensure a smooth planning, booking and modification process. Due to our extensive convenient payment terms, returns will be processed as an agency check unless otherwise noted. Client’s additional attempts to receive additional refunds via charge backs or credit card dispute will be considered a breach of this agreement and potential fraud. Please be sure that you understand and agree with all Terms & Conditions prior to confirming your travel plans. Please feel free to contact our dedicated agents at any time to discuss the Terms & Conditions of your potential travel plans.

I have been advised of potential change/cancellation charges that may be implemented by the supplier in the event that I choose to cancel or change my booking after making the initial deposit.*

I agree

By signing below, I agree to the terms and conditions and confirm the accuracy of the information disclosed within this form and to the authorization to charge my credit card for the amount specified above.

By signing below, you expressly acknowledge your acceptance of these conditions applicable to your purchase and by signing your name and initials you have read and agreed to this being your signature by electronic transfer to Platinum Key Travel Concierge, LLC.

Refunds & Cancellations: Due to the nature of this transaction, refunds will be processed by check once an audit and verification of payment is completed. Chargebacks will not be procesed. Cancellation fees & card processing fees may apply.

Questions, please contact 857.529.7582.

Signature*

Additional Comments or Passenger Information

Enter the message as it's shown*

Note: Your card may not automatically be charged by completing and submitting this form; however, completing and submitting this form does give the agent the right to charge the card for the amount and purpose authorized above.

Payment Information

USDMinimum $100.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Client Information and Credit Card Authorization

Thank you !