• Insurance Waiver & Credit Card Authorization Form

  • Contact Information:   

    Main Street Travel Co.


    PO Box 1362

    White House, TN 37188

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  • Travel Information:

  • Travel Insurance:

  • Passports/Visas:

  • Air Carriers and Baggage:

  • Change/Cancellation:

  • Credit Card Information:

  • Card Holder Authorization

    I, the above-named authorized credit card user, give Main Street Travel Co. and its representative express authorization to charge my credit card for the purposes detailed above. I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all agreed upon (as stated above) charges as well as any and all collection and legal fees. This credit card is authorized for only the charges noted above. By signing this "Credit Card Authorization" form, I/my organization acknowledge receipt and understanding of its contents, including its "Explicit Authorization" clause.

  • Disclosure and Consent

    We make 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. 

    By signing below, you expressly acknowledge your acceptance of these conditions applicable to your purchase and by signing your name and initials you have read and agreed to this being your signature by electronic transfer to Main Street Travel Co.  


  • By signing below, I agree to the accuracy of the information disclosed within this form and to the authorization to charge my credit card for the amount specified above.

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  • Note: Your card will not automatically be charged by completing and submitting this form; however, completing and submitting this form does give the agent the right to charge the card for the amount and purpose authorized above.  You must contact your Main Street Travel Co. Travel Planner for payments to be charged.  It is your responsiblity to contact your Main Street Travel Co. Planner prior to all due/final due dates.  

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