CREDIT AUTHORIZATION
For AirGorilla or its Ticket Processor

1213 First St #206, Coronado, CA 92118
435-216-3906 Reservations

Fax to the number you were given.
 

Unless instructed differently, please fax the following items:
(1) This Authorization Form
(2) Photocopy of Credit Card (Both Sides) and
(3) Photocopy of Driver's License, Passport, or Utility Bill Statement

Please include your six-digit reference code:________________

Fill in CREDIT CARD TYPE

( ) Visa     ( ) MasterCard     ( ) American Express     ( ) Discover Card

Card Holder's Name:____________________________
Credit Card Number:_________________________ (Print Clearly)
CVC Number:_________________ (last 3-4 digits of number on back of card)
Expiration Date:_____/_____
Bank phone (see back of card):___________________
Billing address where you receive credit card statements:
_______________________________________________
_______________________________________________
Card Holder Phone:_____________________________
Card Holder Work Phone:________________________ Cell_____________________

I, the card holder, ____________________________ have read and understand the terms
and conditions of AirGorilla and agree to them completely (click here to review: Terms).
I authorize AirGorilla or its affiliated ticketing agency to charge in full the amount
of $______________________ for travel related service for the following passenger(s):
____________________________________________________
____________________________________________________
(include self in list if applicable)

Sign below that you agree to the conditions on this form.

CARD HOLDER SIGNATURE: ____________________________ DATE:_________________________
Shipping Address for paper tickets (if relevant):
_________________________________________________________