Visa Application and Credit Card Authorization

American Airlines Passengers

TRAVEL AFFIDAVIT- GENERAL/SPECIFIC LICENSES
I understand that travel transactions related to Cuba must be directly incident to one of the self -authorizing general license purposeful travel categories or travel
authorized under the auspice of a specific license granted on a case-by-case basis. Under current US travel restrictions with respect to Cuba, travel-related transactions are
prohibited except for the following categories and that by signing my name at the bottom of this Affidavit, I declare that I fall qualify for one the enumerated categories.
I have checked the applicable authorized category of travel below.
1.

2.

FAMILY VISITS - CFR 515.561

OFFICIAL BUSINESS OF THE U.S. GOVERNMENT, FOREIGN

GOVERNMENTS, & CERTAIN INTERGOVERNMENTAL ORGANIZATIONS
CFR 515.562

3.

4.

JOURNALIST ACTIVITIES CFR 515.563

PROFESSIONAL RESEARCH CFR 515.564

9.

SUPPORT FOR THE CUBAN PEOPLE CFR 515. 574

10.

HUMANITARIAN PROJECTS CFR 515.575

11.

ACTIVITIES OF PRIVATE FOUNDATIONS/RESEARCH/EDUCATIONAL

INSTITUTIONS CFR 515.576

.
5.

PROFESSIONAL MEETINGS OR CONFERENCES CFR 515.564 (2)

6.

EDUCATIONAL ACTIVITIES AND PEOPLE TO PEOPLE EXCHANGES

12.

13.

RELIGIOUS ACTIVITIES IN CUBA CFR 515. 566

8.

PUBLIC PERFORMANCES, CLINICS, WORKSHOPS, ATHLETIC & OTHER

TRANSACTIONS RELATED TO INFORMATION & INFORMATIONAL

MATERIALS CFR 515.545

CFR 515.565

7.

EXPORTATION & REEXPORTATION OF CERTAIN INTERNET-BASED

SERVICES CFR 515. 578

14.

CERTAIN EXPORT TRANSACTIONS CFR 515.533

15.

Specific License

COMPETITIONS & EXHIBITIONS CFR 515. 561

I have a specific license from OFAC, which was issued prior to my trip. My OFAC
Specific License number is
.

For additional information on the individual OFAC categories of travel to Cuba in more detail please visit the OFAC website or the
questions and answers page direct at https://www.treasury.gov/resource-center/sanctions/Programs/Documents/cuba_faqs_new.pdf
One application can be submitted for multiple passengers if they are all on the same booking (record locator). If the passengers
have multiple reasons for travel please submit separate applications for each reason for travel.
Your below signature constitutes an affirmation that you qualify for one the above afore mentioned OFAC travel categories and you will
comply with the travel regulations as they relate to travel to Cuba.
I certify that the above information is true and correct. SIGNATURE:

DATE: 8/18/2016

VISA APPLICATION INFORMATION:

Name #1: ______________________________________________

Airline: American Airlines

Name #2: ______________________________________________

Flight Date: ____________________________________

Name #3: ______________________________________________

Record Locator:_________________________________

Name #4: ______________________________________________

Name #5: ______________________________________________

Shipping Address: ______________________________________

Name #6: ______________________________________________

_____________________________________________________

Name #7: ______________________________________________

_____________________________________________________

Name #8: ______________________________________________

_____________________________________________________

Name #9: ______________________________________________

Visa Application and Credit Card Authorization

American Airlines Passengers
CREDIT CARD AUTHORIZATION
This is a written authorization to Cuba Travel Services [CTS] to debit the amount shown below for the services described.
SERVICES DESCRIPTION

Quantity of Visas: ___________

x
Cost Per Visa: USD 85.00/EACH
Total Price:

0.00
USD_________

CREDIT CARD AND CARDHOLDER INFORMATION

CARDHOLDER NAME AS SHOWN ON CREDIT CARD: _____________________________________________
CREDIT CARD TYPE: (American Express/ Master Card / Visa) _____________________________________________
CREDIT CARD NUMBER: _____________________________________________
CREDIT CARD SECURITY CODE: _____________________________________________
(Visa and Master Card code is located on top of the signature band last 3 digits. American Express on the upper right / upper left / lower right / lower left 4
digits code)

EXPIRATION DATE: ____________________________________________

CARDHOLDER BILLING ADDRESS: _____________________________________________________
_____________________________________________________
CARDHOLDER TELEPHONE NUMBER: ____________________________________________
CARDHOLER E-MAIL ADDRESS: ____________________________________________

If traveler is other than the cardholder provide full name of Traveler below and a clear copy of his/her photo page passport. All services are final and non refundable. Cardholder agrees to pay in full
the services shown above. CTS is a broker of the services shown and is not a direct provider of the services. CTS does not assume any responsibility or services not provided by these companies or
services not used totally or partially by the traveler. By signing this Credit Card authorization, the Cardholder and the Traveler agree to these terms and release CTS of any damage and legal fees
caused by the final provider of the services. CTS fully suggests to Cardholder and Traveler to acquire a travel insurance coverage in case of any unexpected incident that prevents from receiving these
services. CTS recommends Travel Guard insurance service; more information about Travel Guard can be found at www.travelguard.com or by calling 1-800-826-4919. Agcy Code: 010

8/8/16
__________________________
DATE

_____________________________________________
CARDHOLDER SIGNATURE

____________________________________________
CARDHOLDER NAME

Processing Instructions
Please Fax to (310)645-9460
Or
Email to info@cubavisaservices.com
You will receive a transaction receipt at the time your order is processed, followed by an email from FedEx for tracking purposes.
Please contact us at (800)963-2822 if there are any problems with your order.