EFTA00317357.pdf

MPTON® hotels & restaurants Credit Card Authorization Form I :TER--12 el gera.1 hereby authorize following credit card: Hotel/Restaurant Name 3i-oe F jjM6EK froa to process the Guest Name: Confirmation #: Arrival Date: fr lAeCk) Departure Date: A-4 A ito fl `29 , Contact Name: Name on Credit Card (if different from above): c ) E r PPG- y a • IZ Psi-re0J Last Four Digits of Credit Card Number. 3 0 0 ) **To protect your confidential information, do not provide thefidl credit card number in thisform. Please CALL the hotel to provide yourfull credit card number. ** Expiration Date: WI 4, Billing Address: ell GAIT Sc 1O0a1 City/State/Zip: i 0 Daytime Phone Number: Email Address: Authorized Signature: Please Indicate Billing Instruerrs;l:eck "on all that D Banquets E Audio Visual Only D dvance Deposit of S oom and Tax Only cidentals Only n Other (please specify): ** Please note that if a differentform of validpayment is not received at :me ofcheck-in, all charges will be applied to the above credit card.** EFTA00317357