Consent *

By completing and signing this form, I authorize MD Travel to keep my card on file for use on or after the submission date. MD Travel requires written permission from me for any debits or credits to my account, and any terms & conditions related to such charge will be set out in writing prior to the charge being initiated. I understand that such written permission coupled with this form is sufficient to establish a legitimate charge.

I agree to the above

I acknowledge the terms and conditions

Name *

First Name

Last Name

Phone *

(###)

###

####

Credit Card Type *

VISA

Mastercard

American Express

Discover

Card Holder Name *

First Name

Last Name

Expiration *

MM

DD

YYYY

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country