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Post Office Box 3163
Lilburn, GA 30048
(844) 732-2412
info@peachstatediamond.com
CREDIT CARD AUTHORIZATION FORM
FAX TO: 844-732-2412
Peach State Diamond Travel & Tours is authorized to charge
the credit card below for the following charges.
Name of Trip or Destination ________________________________________________________
Date(s) of Trip: __________________________________________________________________
Amount to be charged $____________________
 AM
 Visa
 MC
 Discover
CC# _______________________________________________________ Exp. ___________
Three Digits on Back of Card _________________________
Print Name _____________________________________________________________________
Billing Address __________________________________________________________________
City, State, and Zip _______________________________________________________________
Phone Number __________________________________________________________________
Email _________________________________________________________________________
Signature ______________________________________________ Date ___________________
Signature authorizes Peach State Diamond to charge this credit card for the charges listed above.
Credit card payments cannot be accepted over the telephone without your signature on this form.
Insurance/ Policy Waiver Plan:
 Accepted
 Declined
Please attach a copy of the front and back of the credit card listed above and photo ID with
matching signatures.
Without this information we are unable to process the charges.