Form Builder

Purchaser - First Name

Purchaser - Last Name

Purchaser - Email

Purchaser - Phone Number

Purchaser - Card Type

Purchaser - Credit Card Number

Purchaser - Card Expiry Date

Purchaser - Name on Credit Card

Gift Certificate Amount

Certificate Personalization - From Name

Certificate Personalization - Recipient Name

Send gift certificate to

Should it be sent to the purchaser, or recipient?

Certificate Personalization - Message to Recipient

Write a personal note to be included on the gift certificate.

Authorization

I authorize Tyax Lodge & Heliskiing to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.