203 612 2821, 203 595 5333


In Lieu of My Credit Card Imprint, I Hereby Authorize Mypayanam/or partner payment gateway to charge an Amount totaling USD .My American Express / Visa / Master Credit Card No CVV: Expiry .
Credit Card 24 hour Card member Service Tel. #:
- Refunds may take up to Ten(10) weeks depending on the airline.
- Penalty for the above ticket(s) is: fr $375+* per ticket
- recall commssion or discount if any+4% merchant fee
- I am aware of the penalty and authorize Mypayanam to cancel my reservation.
- If your ticket is refundable or changeable, it must be canceled 24 hours (working day(s)) before departure to be eligible for refund or date changes
For Transportation for Myself and/or .

*Relationship: (W: Wife - D/S: Daughter/Son - P: Parent - O: Other please state

1. (M/F) Date of Birth: *Relationship:
2. (M/F) Date of Birth: *Relationship:
3. (M/F) Date of Birth: *Relationship:
4. (M/F) Date of Birth: *Relationship:
5. (M/F) Date of Birth: *Relationship:

My Billing Address for the Credit Card used is:
Street: City/State: Zip:
Home Phone: Business Phone: Fax: E-mail:
I will support this authorization with scanned copies of my credit card (front and back) and a federal ID such as a valid driver's license.

By signing below, I acknowledge full liability for the charge described payment in full will be made when billed in accordance with standard policy of bank issuing the card.Also by signing I accept the terms and conditions

E-mail or Fax this from back to your sales agent @203 595 5333 or

SIGNATURE: _________________________________     DATE: _______________

All Form must be received before 5 PM EST for ticketing and no exception(s)
Fare Quoted Subject to Change without notice and Mypayanam Tours & Travels not responsible for any fare change