RCS1005PE-DPO

Rovia Escapes Membership Enrollment & Payment Authorization Form

Employee Information
Full Name (Last, First, Middle) Date of Birth (MM/DD/YY) (must be 18): Address (NO P.O. Box): Address 2:

City:

State:

Zip:

Home:

Mobile:

Email (Required):

Employer:

Employee #:

Select the payment method described below: I hereby authorize Rovia Corporate Services, LLC (RCS) to immediately withdraw a one-time enrollment fee of $20.00 and recurring monthly service fees of $24.99 for my Rovia Premium Escapes Membership from the credit card or bank account identified on below. The first months billing will be $44.99 with subsequent months billed at $24.99.
**Please Choose ONE Form of Payment.**

ACH Payment

Bank Name: _________________________________________ Bank Telephone: ___________________________ City: ________________________________________________ State: _______ Zip: _______________________ Routing #: __________________________________ Account #: _________________________________________ Card Type:
MC VISA AMEX

Credit Payment

Name on Card: _________________________________ Credit Card#: ___________________________________ Exp. Date: ______/______ 3-Digit CVV2 Code: _______ Billing Phone Number: _________________________

Billing Address: _______________________________________________________________________________ City: ___________________________________________ State: ________ Zip: __________________________

I HAVE CAREFULLY READ AND AGREE TO ALL THE TERMS AND CONDITIONS ON THE FRONT AND BACK OF THIS AGREEMENT. I understand that this Agreement will remain in effect until I cancel this Agreement through one of the methods specified on the back. I affirm that none of the spaces intended to be filled out by me have been left blank. I am aware that I am entitled to a copy of this Agreement at the time I sign it. I may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction (5th business day if I reside in AK; 30th day if I reside in KY; 5th day if I reside in WI). This authorization is to remain in full force and effect unless I provide written notification to Rovia within 5 business days prior to monthly billing date or as otherwise provided in the Terms and Conditions on the reverse of this Application.

Applicants Signature: ____________________________________________________

Selling Representative (Enroller) Information:

Date: _______________

Name: ______________________________________________________Rep ID#: ______________________________

ROVIA CORPORATE SERVICES, LLC 5360 LEGACY DR., BUILDING 1, SUITE 300 PLANO, TX 75024 PH 972. 805.5215 FAX 972.767.3945 WWW .ROVIACS.COM CST # 2094843-40 FL SOT #ST37441 HI SOT TAR6636 IA SOT #934 WA SOT #602895305

Ver 2.1-PE-DPO Rev 2013

TERMS AND CONDITIONS

1. I authorize Rovia Corporate Services (RCS) to immediately withdraw onetime and monthly Rovia Escapes Membership fees from the credit card or bank account that I have selected on the front of this agreement. I understand that such sum will be deducted from my credit card or bank account every month until I change the method of payment or until I cancel this authorization as provided herein. 2. This authorization will remain in effect until member notifies RCS in writing that member does not wish to continue the Rovia Escapes Membership. Such cancellation shall take place immediately. Alaska Residents: You may cancel this Agreement without penalty or obligation within five days of the date of the Agreement and receive a full refund. See the below Notice of Right to Cancel. Kentucky Residents: You may cancel this Agreement without penalty or obligation within thirty days of the date of the Agreement and receive a full refund. See the below Notice of Right to Cancel. If you cancel after thirty days, you will be entitled to receive a pro rata refund without deduction for benefits received. New Hampshire Residents: If you cancel this Agreement more than three business days after its execution, you are entitled to a pro rata refund of your Membership fees without deduction for benefits received. Wisconsin Residents: You may cancel this Agreement within three months or within three days of your first purchase under the Rovia Escapes Membership, whichever occurs first. If you cancel within the first fifteen days of Membership, you will receive a full refund of your Membership fee. If you cancel within three months of this Agreement or within three days of your first purchase (whichever occurs first), you will be entitled to a pro rata refund of your Membership fee, without deduction for benefits received. 3. Rovia. Escapes Members may purchase the goods and services described at the member-only Rovia Escapes web site (www.roviaescapes.com). Travel services are fulfilled by Rovia, LLC (Rovia). Such goods and services may only be purchased through such web sites without opportunity for inspection. You may be required to pay freight costs, handling fees, and other costs incidental to the purchase of such goods or services. The goods and services available through Rovia Escapes membership are purchased from third party vendors and not RCS or Rovia. RCS & Rovia make no representation to the quality of such goods or services provided by the aforementioned third party vendors. Rovia shall provide you with all the information that has been provided to it about each trip. 4. I agree that the goods and services available through Rovia Escapes membership are purchased from third party vendors and not my employer. My employer makes no representation to the quality of such goods or services provided by the aforementioned third party vendors and I agree to hold my employer harmless in the event that I am dissatisfied with the services or products provided by the aforementioned third party vendors. 5. Rovia Escapes Members may take dependent children on Escapes vacations, however the pricing for children is particular to each Escapes vacation and will change accordingly. See the Rovia Escapes website or each Escapes vacation-specific brochure for details. Dependent children are those children residing with their parent(s) or legal guardian(s), in school and 18 years of age or under. Those children who are over the age of 18, un-married, residing with their parent(s) or legal guardian(s), and full-time students (up to the age of 25) are also considered dependent children. In addition, a child that is permanently handicapped (no matter what age) and under the direct care of his or her parent(s) or legal guardian(s) is a dependent child. 6. I agree that it is my responsibility to choose which Escapes vacation I purchase and that electing to not participate in all or any of the Escapes vacations offered does not constitute a breach of this agreement. I further agree that I will not be eligible for a full or partial refund of my Membership Fee and Monthly Fees as a result of my non-participation in any of the Escapes vacations offered by Rovia except as provided in paragraph 2 of these Terms and Conditions. 7. I agree that due to the inherently limited inventory in the travel industry, the published price for each Escapes vacation is not guaranteed to all members regardless of attendance volume. I further agree that Rovia will make every available opportunity to offer me the best possible price but that prices may increase above the initially published price due to limited inventory availability. 8. I agree that the full Terms and Conditions of my Membership will be provided to me when I first access the Web Site and I will not be able to use my membership until I have accepted the full Terms and Conditions. My Membership and the agreement relating to my Membership will not be accepted by RCS or enter into force until I accept the Terms and Conditions of Membership.

NOTICE OF CANCELLATION DATE OF TRANSACTION: ______________ Name (Please Print): _________________________________________

You may CANCEL this transaction without penalty or obligation, within THREE BUSINESS DAYS from the above date (Five business days if you reside in Alaska, thirty days if you reside in Kentucky, and fifteen days if you reside in Wisconsin). If you wish to cancel this agreement, you may do so by delivering or mailing a written notice to ROVIA CORPORATE SERVICES. To prove that you canceled, it is recommended that you send the notice by certified mail or overnight delivery. If you deliver the notice personally, you are entitled to a receipt. Your notice must state that you do not wish to be bound by the agreement. Be sure to keep a photocopy of the notice of cancellation which you mail. Notice of cancellation, if given by mail, shall be deemed to be given as of the date the mailed notice was postmarked. If you cancel, any property traded in, any payments made by you under the contract of sale, and any negotiable instrument executed by you will be returned within TEN BUSINESS DAYS following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. To cancel this transaction, mail or deliver a signed and dated copy of this Cancellation Notice or any other written notice, or send a telegram to Rovia Corporate Services, LLC, 5360 Legacy Dr., Building 1, Suite 300, Plano, TX 75024 NOT LATER THAN MIDNIGHT OF the third business day following the date set forth above.

I HEREBY CANCEL THIS TRANSACTION. Signature: ___________________________________________________ Date: ____________

Keep one copy of this Agreement and give another copy to the Selling Representative to be entered into the RCS ordering system.

ROVIA CORPORATE SERVICES, LLC 5360 LEGACY DR., BUILDING 1, SUITE 300 PLANO, TX 75024 PH 972. 805.5215 FAX 972.767.3945 WWW .ROVIACS.COM CST # 2094843-40 FL SOT #ST37441 HI SOT TAR6636 IA SOT #934 WA SOT #602895305

Ver 2.1-PE-DPO Rev 2013