EFTA00313628.pdf

TIIE Ruh[ -t I NI* Credit Card Authorization Form II '711C. In Dear Guest, This form has been created in order to alloo you to have third party expenses charged to your credit cant Please pnnide all the information requested below to ensure prompt processing of your application. We ask yo r i the form before submission. Please fax the completed form to the attentio n of Front Office. fax Cardholder Information Name as It appears on the credit card: j --- rit'seGNI eps-r-g.ii.1 Card type: CI Visa El MC Ea Amen ❑ Dblersial U Discover JCR Account type: Cr Individual (personal) U DEBIT CARD Cagsturr CARD D Corporate I Company Name: Account number. Exp. date: C- I I Address: ,.hat ass..install L= AST M ST SI TA :11--> r City. State and Zip: ELJ • Phone number: Fax or alternate number: Goat 'reformation Guest name: -PHILAwe \JA ),A Company: Phone number: Fax or alternate number Confirmation number. Arrival date: Fa or. I Separture date: Fe6 JO. Relation to cardholder: CI Relative CI Friend a - fiusiness Associate lj Other. Rate Information aid Ammpved_Chantes Room rate: Taxes:* Total daily rate:* Number of nights: *(Rate and tax amount must be provided by a hotel representative in order to complete this form) ~AIICharges CI Room & Tax j Telephone (LD) ❑ Telephone (Local) CI Restaurant j Room Service lj Valet (Laundry) U Parking U HS Internet Access j Movies X Other: I catty that all internal= is compkic trel tannic. I tetchy audacity Ibt etka-Carleat Sr. Means to <aka symere Ste Sae letcoccelion led Apprond Charges season of this form tot ell chutes as imitated in by lactates a charpe tomecraht cad listed above. °sopa must cc foe the entire ststy.ttast I unearned ant a new form sall ten not exccoi to be complesed If typal wishes to exited hostler say I and) that 1 in the embolued arm of the =ducats' hissed abuse. Cardholder name. memo Cardholder signature: Date: cj - eP) . Ts a-or+ 7 Tbab4 ......."C••••••.L LC -am • Ni. 2, EFTA00313628