icna i Third Party Credit Card Authorization Forr International Exchange of North America Please complete all detals below Please write clearly the details pertinent to your credit card. JENA accents Viea, American Exprass and Mastercay This f Participant rome balay see Gomailace — Ceainp attending Camo Manced First Name. Jaleo Pa bre (AS SEEN ON CREDIT CARD) vastneme_£y facia Sabana (AS SEENON CREDIT CARD) is to supplarnent cur online payment system and is competed if participant is using a ret car frm that does not belong to them with permission ofthe ov Street Address 6 de f at- Y, (WHERE YOU GET YOUR CREDIT CARD LL) City Pebla state/Province Plea Zip Code. 22540 country Mexico Email de reroev Frag @) Ex, Credit Card Number 477-2. J3 30.56 06 $932. exp Date (mm/yy)_()2/ 2029 AMOUNT TO CHARGE. p 425 Three/Four Digit Security Number (On ac of Matercard/Visa, on font of AMEX) | give authorization to the participant listed above to use my credit card to pay all fee's owing to IENA. have read and agree to the terms and conditions of the Program Agreement. | understand as per the 3 Adventures Program, Agreement that the person authorized to use my card agreed to when creating their account that if they fail to complete their camp contract, they may be responsible for fees that would otherwise be paid fo 3 Adventures by camp. These fees will be charged to this credit card which will be held on file: “4, Fallre to complete your camp contract, or any reason, wil resi nthe cancelation of your 1 visa status. You wil be requteso cetum to your country of resktence onthe earbest available fight Without prejudice to any other cleims IENA may have, you willbe responsible for any flight change fees and ‘willbe lable for any fees that would otherwise be paid by your camp to IENA (up to £1000) nthe avert hat any invoice fs not paid when due, the bedi card on le wil a butematicaly charged, ithe charge rejected, all cst incured Ih recovering the outstanding balance wil be added othe outstanding Signature F ie Date _()3/24/ 202.3