Payment Form

Card Holder name *

First Name

Last Name

Credit Card Information *

Card Type

Mastercard

Visa

Discover

Amex

Other

Expiration Date *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Acknowledgement *

I am agreeing to the above amount to be charged by Lux Family Vacay. ***Please note that this is only an authorization to pay the vendor. Your card will not be charged immediately.

Agree

Disagree