AUTHORIZATION FOR CREDIT CARD USE

Print and complete this authorization and return.

(All information will remain confidential)

Name on Card: LELOUCY RAPHAEL ANDRE

Billing Address: 22 RUE JEAN JACQUES ROUSSEAU 78520 LIMAY

Credit Card Type: Visa X Mastercard Discover Amex

Credit Card Number: 5325 0900 3621 1777

Expiration Date: 06/2023

Card Identification Number: 137 (last 3 digits on the back of the credit card)

Amount to Charge: $ 2,460,3 (USD)

I authorize Travel-Rite Tours and Travel, LLC to charge the amount listed above to the credit
card provided herein. I agree to pay for this purchase in accordance with the issuing bank
cardholder agreement.

Cardholder – Please Sign and Date

Signature:

Date: 14 / 09 / 2021

Print Name: LELOUCY RAPHAEL ANDRE

Return the completed and signed form to the following:

Travel-Rite Tours and Travel, LLC with Luxevo Vacations
Sylvia Grandberry
sylvia@luxevovacations.com