Authorization Form Credit card authorization: AMEXVISAMCDiscover Card number: Expiration date: Security code: Phone number: Name on card: Billing address: City: State: ---AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Zip: Your email address: I agree to pay for purchase of travel services in the total amount of: Trip details: Trip begin date: Trip end date: Your trip description (optional, feel free to include as many details as you like): Traveler Information (as on the official ID used for travel): Information must match your ID or you may be denied travel. Please include children that don’t have ID, if applicable. Please contact us if more than five travelers. Last name First name Middle Birthdate Gender Last name First name Middle Birthdate Gender Last name First name Middle Birthdate Gender Last name First name Middle Birthdate Gender Last name First name Middle Birthdate Gender Travel Insurance: I understand that I have the option to purchase travel insurance to cover potential travel related losses due to issues out of the control of Navigo Travel. Please refer to our travel insurance page for more information. Yes. Please include travel insurance.No. Please exclude travel insurance. Electronic Signature: I certify that I represent myself and all travelers on my travel itinerary and I have or will communicate all terms & conditions and travel insurance information to my traveling companions. I authorize that my credit card be charged for the amount(s) indicated above. I have confirmed that all names match official identification. Type your full name: Date signed: I understand and agree with the Navigo Travel Terms & Conditions.