EFTA00310526.pdf

inlet Credit Card Authorization Form Please fax a copy of your Drivers License and Credit Card along with this form back to 877.408.0041. Client Jege LLC Attention: Phone: Fax: Email: Trip Details Quote Num: 23274 Salesperson: PETER Credit Card Information Credit Card Number: Vcode: Larry Visoski Travel Date(s): 09/08/2014 Itinerary: SAF-IAD I IJ Card Expiration Date: I I I Total Charges: $23,163.95 Charge above includes e-transaction fee of 5% Card Type: [ ] Visa [ ] MasterCard [ ] American Express Cardholder's Name and Card Billing Phone Number: Card Billing Address: Select Payment Option: (check option) Note: Quote is not confirmed until funds have been secured using one of the following methods. Credit Card above will be authorized for all options Prepay by wire transfer required 84 hours prior to any aircraft movement associated with flight request. Bookings within 84 hours will be handled on a case-by-case basis. Payment to occur Net 10 upon flight completion date of the above schedule. I will adhere to the terms and conditions of the Injet Credit ApplicationlAgreement. Subject to approval. Authorize the above card and then charge above card upon completion of the flight(s) Prepay Discounted Amt: $22.060.90 Net Payment Amt: $22,502.12 Credit Card Charge Amt: $23,163.95 Signature Details By signing this "Credit Card Authorization Form" I am accepting the "Total Charges" represented and that the credit card I have provided will be the primary method of payment. I understand that in the event I select the invoicing payment method to settle my account, and InJet does not receive payment within 10 days from the start date of the flight, the credit card will be charged the "Total Charges" amount plus any applicable surcharges. By signing, I guarantee that the credit card I have provided is capable of supporting the above charges, is herby authorized for that usage, and I agree to make payment according to my "Card Issue Agreement" terms. PLEASE INITIAL HERE TO CONFIRM UNDERSTANDING OF THE ABOVE For ACP Office use only Date Obtained Rep Phone 4145 Southern Blvd. Suite 5-8 Wee Palm Reach Fl 33406 Email: EFTA00310526