FOR OFFICE USE ONLY

Date received <empty>
Date of trip <empty>
Travel specialist <empty>

# UNCHARTED OUTPOSTS
SAFARI & TRAVEL CO.

CREDIT CARD AUTHORIZATION FORM

NAME ON CARD <empty>
(Please Print)

Type of Card:
[ ] Visa
[ ] MasterCard
[ ] American Express
[ ] Discover

Credit Card Number: <empty>
Amount: <empty>
Security Code: <empty>
(On Back of Card)
Expires: <empty>
(Month/Year)

[ ] Please check this box if we may use this credit card for purchase of travel insurance.

Mailing Address: (as appears on your billing statement)
Street <empty>
City <empty>
State <empty>
Zip <empty>

I do hereby authorize Uncharted Outposts to charge my credit card in the amount of US Dollars
for my travel arrangements and take full responsibility for the above charges.

Cardholder's Signature: <empty>
Date: <empty>