Payment and Travel Authorization Form

Authorization for Payment and Travel Information

Secure Credit Card and Travel Detail Submission

Please complete the form below to authorize Luxotic Retreats to charge your credit card for the agreed-upon purchases or services. This form also securely collects passport details and optional TSA information to support travel arrangements and ensure timely, accurate processing.

Cardholder First Name

Last Name

Phone

Card Type:

Visa

MasterCard

American Express

Discover Card

Card Number

Expiration Date

3 or 4 Digit Code

Billing Zip Code

Passenger #1 Passport Upload

Upload File

Upload supported file (Max 15MB)

Passenger #2 Passport Upload

Upload File

Upload supported file (Max 15MB)

Passenger #1 TSA Redress Number (optional)

Passenger #2 TSA Redress Number (optional)

Passenger #1 TSA Known Traveler Number (optional)

Passenger #2 TSA Known Traveler Number (optional)

By signing below, I authorize Luxotic Retreats to charge the credit card indicated above for the amount listed in the travel quote received. I certify that I am the authorized cardholder or have permission from the authorized cardholder to use this card.