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Dioduet Travel Po Box 363, Jacksonville, IL 62651 PH# 312-252-9488 F#312-254-3409 dioduet@yahoo.com

2014 Palm Beach Week Credit Card Authorization & Booking Form (This is a Nonrefundable Purchase)

I, ____________________________________________________, hereby authorize Dioduet Travel and applicable vendors, to make charges to my credit card for this

package. Pleas note the number needed in the appropriate box. For packages, pricing is per person, based on 2 sharing a room. If travelling as a single, please add an

additional $2,500 to the price for the Palm Beach week & $1,075 to the price for the charity weekend.

Full Palm Beach Week: $7,910 ea ____ Charity Weekend:$3,780 ea___ Golf VIP upgrade for packages: $750 ea ____ Day at the Breakers/Golf only $800 ea: ____

Day at the Breakers/VIP Golf: $1,500 ea___ Day at Polo : $500 ea____

Please provide the following information in detail. Please be advised that any incorrect/incomplete information provided may cause issues with events and hotel.

1. Print name as on ID: Sex: D.O.B. ___/___/___ Golf handicap:____ Email:

2. Print name as on ID: Sex: D.O.B. ___/___/___ Golf handicap:____ Email:

3. Print name as on ID:

Sex: D.O.B. ___/___/___ Golf handicap:____ Email:

4 Print name as on ID: Sex: D.O.B. ___/___/___ Golf handicap:____ Email:

I fully understand that all payments are nonrefundable and any purchase that is made on my/our behalf of airline tickets, hotels/resorts, tours and other travel services or products are non-refundable and are subject to change fees in the event changes need to be made. I also acknowledge that due to this being nonrefundable, that I was offered travel insurance in order to protect myself from any financial losses & that if I declined, I take full responsibility, for myself & my travel party, of the financial burden that this may cause. By signing this form, I confirm that all submitted travel information by the agency has been reviewed and is accurate. I also confirm that the information that I have provided on this form is accurate and take full responsibility, if it is not. Dioduet Travel, its affiliate(s), independent marketers and independent contractors or the charity/charities represented, are in no way responsible for the operation of any hotels, resorts, tour operators, airlines or programs, serviced etc, that are affiliated with this reservation. So, I hereby agree to indemnify and hold blameless & harmless Dioduet Travel et al., from and against any and all judicial and non-judicial claims, by direct result or indirect result of any bookings/travel services made on my behalf or any bookings charged on my credit card for someone else’s behalf. I also confirm that my signature and payment, binds the above referenced travelers to this agreement. I also understand that an additional 4% will be charged for all credit card charges. Tour components are subject to change without notice. In the event the tour is cancelled, and full payment has been received, a full refund will be provided.

Credit Card Type: Visa ___ MasterCard ___ American Express ___ Billing Name (as it appears on credit card):

Credit Card Number: _____________________________ Expiration Date: _______ Security Code:____

Billing Address (where credit card statements are sent to):__________________________________________________________________________________

Daytime Telephone Number: ___-___-_____ Evening Telephone Number: ___-___-_____ Email:______________________________________________

Authorized Cardholder signature: ________________________________ Date:___/___/_____

*** PLEASE PRINT THIS PAGE OUT AND FAX TO 312-254-3409. PLEASE INCLUDE A COPY OF THE CREDIT CARD, BOTH FRONT AND BACK, ALONG WITH YOUR PICTURE I.D.

(DRIVER'S LICENSE, MILITARY I.D., ETC.) ***