Credit Card Authorization Form

PLEASE READ THIS BEFORE YOU CONTINUE: FORM MUST BE COMPLETED IN FULL, SIGNED BY
AN AUTHORIZED USER OF THE CREDIT CARD, ALONG WITH A CLEAR COPY OF THE CREDIT CARD BOTH SIDE AND
AUTHORIZED USER PASSPORT AND DRIVER`S LICENSE SHOWING SIGNATURE AND PICTURE.

-------------------------------------------LIDIA SALAZAR ------------------------------------------------BY EXECUTING THIS (NAME AS IT

APPEARS ON CREDIT CARD)
AGREEMENT UNCODITIONALLY AUTHORIZES HEALTH TO TRAVEL & TOP VACATIONS TO CHARGE THE FOLLOWING
CREDIT CARD:

CREDIT CARD TYPE: (CIRCLE ONE) Aamerican express

CREDIT CARD NUMBER: -------377481312170076--------------------- EXPIRATION DATE: -------03-24----CW 2 CODE: -----969------------

(EXAMPLE BELOW) FOR THE AMOUNT OF: $1978 USD------

CARD HOLDER`S ADRESS:

STREET: ----1875w44pl apartment 311a ---CITY: ------HIALEAH--------------STATE: ------------FLORIDA-------- ZIP CODE: ------33012---------

---- PROVINCE: ---------------------------------------------COUNTRY: ---------------------------------------------------------------------------------

---------------------------------------------- ------------- ------- ----------------------------------- CARD HOLDER AUTHORIZED

SIGNATURE DATE

I CERTIFY THAT THE ABOVE STATEMENTS AND INFORMATION MADE IN THE AGREEMENT ARE TRUE AND CORRECT TO THE BEST
OF MY AKNOWLEDGE. I ALSO CERTIFY THAT I AM AUTHORIZED IN EFFECT CHARGES TO THE ABOVE CREDIT CARD NUMBER.