NAME ON CARD tialotTED OUTPOSTS SAFARI & TRAVEL CO. ? FS CREDIT CARD AUTHORIZATION FORM FOR OFFICE USE ONLY Date receited ot VIP Travel spedakt (Please Print) Type of Card: O Visa El MasterCard O American Express O Discover Credit Card Number: Amount: Security Code: Expires: (On Back of Card) (Month/Year) O Please check this box If we may use this credit card for purchase of travel Insurance. Mailing Address: (as appears on your billing statement) Street City State Zip I do hereby authorize Uncharted Outposts to charge my credit card in the amount of US Dollars for my travel arrangements and take full responsibility for the above charges. Cardholder's Signature Date Uncharted Outposts I p: 505.795.7710 505.795.7714 I www.unchartedoutposts.com EFTA_R1_01520600 EFTA02444234