EFTA00314079.pdf

riRENZE CREDIT CARD AUTHORIZATION FORM Credit Card Type A M Credit Card NumberMEM Expiry Date le/ c) I Name of Cardholder TErYK PSTE~r.I Address where statement of account is mailed: Street 7 E4ST 3-)sr City Mew ca.e._ State Country (ASA I authorize Relais Piazza Signoria to charge for my reserv ation the above credit card number for the amount of Euro -3a C.-,c C 6LARQ..5 Check-in..N0V%% - Check-out.. 14 Q.V. 3, atie Total nights are .3.. Total amount is turn This reservation cannot be canceled. Cardholder signatur Raids Pima *nods Vacchereals, 3 50122 Wylie Tel..39 055 3987239 Fax .39 055 2863C6 EFTA00314079