EFTA00313980.pdf

Fell 0 MI E S tit I lr n S 13 lr I-4 I L- T ICI 11,4 Address: 105 Hospitality Drive, Plowood, MS 39232 Credit Card Authorization Form In lieu of my credit card imprint, I C*-PE-TG hereby (Print name of cardholder as shown on card) authorize m &- lc A,-) G.- -MVE57 Carla el 0/3 to charge my AtueRACtiN1 Ouulne rarrierritrauol arrant'. name) (Credit Card Type) e g-pgsics (Credit Card Number) (Expiration Date) in me amount of $ 11200. O a for payment of accommodations for myself and/or (Include total for rooms and tax) &OtJ II G4-7- 931 (Full name of guest (s) If other than cardholder) Confirmation Number (s)) lb of Rooms Rate Tax Other Total Check in Check Out 1— ta3. '9 ' ,/ / *(t ),o0 Date Date SAN( at-i My Credit Card Address: I "SAni 30;;; 0 t 9 Office ft: Email A ress: By signing below I acknowledge charges described cc nem. Payment In full to bo made when billed or in extended payments In accordance rd aelky of COT ny issuing the credit card in the event the hotel is required to issue a refund or credit, a 5% merchan will be • cted f e total amount. r )c0' ' a--ra e l ure of holder) (Date) LJ Place front of Credit Card EFTA00313980