EFTA00310257.pdf

Tla RfrZCARD-Cr4. Credit Card Authorization Form St. Mkt Dear Sir/Madam, This form has been created in order to allow you to have third party expenses charged to your credit card. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please sign and date the form before submission. Please fax the completed form to 310493-3839. Cardholder Information Name as it appears on the credit =4: -Te-CC,ce C. Eps4en Card type: Visa D MC ZI Amex DinersiCB CI Discover LI CB CI Account type: ZI Individual (personal credit card) ❑ Corporate I Company Nam= Account number: (.0)NCO 129. \ Exp. chte: s;\ q CI crA Ths1 sme-t- Address: NI.rertrwrini•arsre City. State and Zip: NleW \\C.Kt, t\\rk).) \Of k(Dog k Phone number a•-)- -1s )O-cA%cif3 Fax or alternate number Guest Information Guest name: Leske\A G,(occ Comps Phone number: Fax or alternate number Confirmation number: Arrival date: Departure date: sec\ .; )?(, D,3015 Relation to cardholder. ❑ Relative Q Friend V Business Associate CI Other Rate Information and Approved Choral Room rate:* Taxca:• row daily rate:* Number of nights: '(Rate and tax amount must be provided by a howl representative in order to complete this form) V All Charges D Room & Tax D Tcicphone(LD) Q Telephone (Local) CI Restaurant CI Room Service El Valet (Laundry) D Parking Q HS Internet Access CI Movies LI Other: I certify that all information is complete and accurate. I hereby authorize THE RITZ-CARLTON CLUB to collect payment for all charges as indicated in the Rate Information and Approved Charges section of this form by processing a charge to the credit card listed above. Charges must not exceed - for the entire stay/event. I understand that a new form will have to be completed if guest wisherfo-ectend hisrber stay. I certify that I am the authorized signer of the ed above. Cardhoder name: orwwe ek4re-i,p I k Cardholder signatac: Date: - ate — tags IL L *WPM MD EFTA00310257