Third Party Credit Card Authorization Form

Please complete all details below.Please write clearly, the details pertinent to your credit card. IENA accepts Visa, American Express and Mastercard

This form is to supplement our online payment system and is completed if a participant is using a credit card form that does not belong to them with permission of the owner.

Participant Name
Daniela Benavidez Hernandez
Camp Attending iena
First Name Jose Maria
(AS SEEN ON CREDIT CARD)

Last Name Zepeda Carrillo

(AS SEEN ON CREDIT CARD)

Street Address Hermenegildo Galeana 58, Col. Tepeyac

(WHERE YOU GET YOUR CREDIT CARD BILL)

CityPuebla State/Province Puebla

Zip Code 72210 Country México

Email dani2112b@gmail.com

Credit Card Number 5263540112421264

Exp Date (mm/yy) 12/2024

AMOUNT TO CHARGE $200

Three/Four Digit Security Number 400

(On back of Mastercard/Visa, on front of AMEX)

I give authorization to the participant listed above to use my credit card to pay all fee’s owing to IENA.

I have read and agree to the terms and conditions of the Program Agreement. I 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 to 3 Adventures by camp. These fees will be charged to
this credit card which will be held on file:

“4. Failure to complete your camp contract, for any reason, will result in the cancellation of your J-1 visa status. You will be required to return to your country of
residence on the earliest available flight. Without prejudice to any other claims IENA may have, you will be responsible for any flight change fees and
will be liable for any fees that would otherwise be paid by your camp to IENA (up to £1000). In the event that any invoice is not paid when due, the
credit card on file will be automatically charged. If the charge is rejected, all cost incurred in recovering the outstanding balance will be added to the outstanding
amount.”

Signature Date 31/10/2023