Responsible Party Name

Personal Credit Card

Credit Card Number*

CVV*

Expiration Date*

Amount*

Card Type*

VisaMastercardAmerican ExpressDiscover

Billing Address*

City*

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Zip Code*

By checking below you accept and agree to the terms & conditions. You accept the following:

I, Cardholder of the debit/credit card (whose details are set out) hereby authorize Ansura Vacations LLC (“AV”) to charge the referenced debit/Credit card. Accordingly, I hereby irrevocably and unconditionally authorize “AV” to charge to my debit/credit card all the Amounts due and payable and I shall be liable for the payment of all the Amounts so charged to my debit / credit card. Your credit card statement will also reflect charges S.O.S Entertainment (via Square).

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