Alanita Travel - ACH Form

ACH Authorization Form

Please Fax this to (617) 701-1750 or scan it as a PDF FILE ONLY to alanita@alanitatravel.net
This form must be FULLY completed before tickets can be issued.
To: Alanita Travel^®, 87 Common Street, Watertown, MA 02472
Ph: (617)923-4810 Fax No:(617) 701-1750

ONE TIME ACH PAYMENT AUTHORIZATION FORM

By signing this form you gave us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

**Please check your itinerary for name spellings. We do not use this page for spelling corrections***

Total number of passengers:
Lead Passenger:

Last name / First name as in the passport:

Date of Birth:

Gender:

Airline:
Passenger India phone# :
Passenger Email:

I, (Account holder) authorize Alanita Travel^®

to charge my bank account indicated for $ (amount) on or after (date)
,and request Alanita Travel^® to issue the tickets below. I am aware that the conditions of my
airline ticket are not mentioned here and that these conditions are stated in my itinerary.I am
responsible for all the conditions of the tickets I am authorizing to be issued.

Billing Address: Add:

Add:

City:

State:

Zip Code:

Account Type:

Name on Account:

Bank Name:

Account Number:

Bank Routing# (normally on left side of check):

Signature here: X_____________________________

Date:____________________