BroMil Consulting Disclosure Consent, Travel Insurance and Credit Card Authorization Form
Complete the information below to begin processing your travel information and payment(s). Your travel consultant will follow up within one business day.
Please fully complete each section of
this digital form.
Please list the best contact number to
reach you regarding questions about
or additional information needed
related to this form submission.
Please list full airport name or code.
Please complete the passenger information at right. Include full legal name for all travelers (as it appears on government issued identification / passport). If you need additional space please utilize the "Additional Notes" section.
**NOTE** If utilizing the 'additional notes' space at right to add additional travelers please be sure to include full legal name (first-middle-last) as well as date of birth (MM/DD/YYYY) and and special notes for the traveler(s) listed. For large groups (10+ travelers) please list "ADDITIONAL GROUP MEMBERS PLEASE CALL" in the space provided and your agent will contact you to collect further details.
I have been advised of the option to purchase travel insurance and agree and understand that my investment may be at risk if insurance is not purchased. My Travel Agent has advised me of the costs of this service should I elect to purchase it.
I have been advised of passport / visa requirements related to my travel. Completion of the information at right confirms that I agree with these statements.
Processing Method (PAYMENT)
Please select your desired level of payment processing (FULL PAYMENT, DEPOSIT PAYMENT ONLY or ALTERNATE AMOUNT) and the appropriate payment method: Visa (V), MasterCard (MC), American Express (AMX) or Discover Card (DSC). List FULL NAME as it appears on the credit card. Please note that the MINIMUM amount due to secure your booking is the minimum deposit amount given to you by your Travel Agent.
Change/Cancellation Disclosure and Consent:
BroMil Consulting makes every effort to honor the package price quoted originally, however; under certain circumstances your price may be subject to increase prior to full payment due to an increase in the cost for one or more of the travel components of your package. Prices will not increase after you make full payment, except for charges resulting from increases in government-imposed taxes or fees. Cruiselines have a right to charge a fuel surcharge, per their policies. By digitally providing your information where requested and selecting the 'Submit Form' button below you expressly acknowledge your acceptance of these conditions applicable to your purchase. Furthermore, by providing your name and/or initials you acknowledge you have read and agree to this being your signature by electronic transfer to BroMil Consulting.
I confirm that all names and dates of birth listed within this form are as they appear on the respective government issued identification for each named person. I acknowledge that 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. Furthermore I, the authorized credit card user named at right, give BroMil Consulting and it's representative express authorization to charge my credit card for the purposes detailed within this consent form. I understand that this form constitutes a legally binding contract and that by affixing my digital signature to this form, I will be held responsible for all agreed upon (as stated within) charges as well as any and all collection and legal fees. This credit card is authorized for only the charges noted within my travel confirmation, provided by my BroMil Consulting travel representative. By providing my digital signature at right, I/my organization acknowledge receipt and understanding of its contents.
Fees will not automatically be processed by completing and submitting this form; however, completing and submitting this form does give the agent the right to submit charges for the amount and purpose authorized in connection with your booking. Please list only the last four numbers of the card. This is for your safety and security (your travel agent will contact you to obtain the full card information).
CCV/CV2 is a security code located directly on the card. Visa, MasterCard and Discover show three numbers on the back of the card, usually within or near the signature panel. American Express shows four numbers on the front of the card.