EFTA00313629.pdf

Xarnott, HOTELS & RESORTS Credit Card Authorization Form Dear Sir/Madam, This form has been created in order to allow you to have third party expenses charged to your credit/debit 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 (Reservations Department at (340-715-6191 Cardholder Information - Required Name as it appears on the credit/debit card: T i r RAE:9 E • cps T.G. Card type: 0 Visa 0 MC erAmex K Dinera/CB K Discover K JCB Account type: Eri elenostal ID emporia. I Company Name: Issuing Rank: Phone rt Account number. Exp. Date: Address: Mtn oaten« n ~NW G4g—r 9 -Ist City. State and Zip: Nek.4) 90CCI Ng 1OOa) Phone number: a ) - talt q 09S- fax or alternate number. Guest Information - Required Guest name: kEvir.1 OuvAG: Address kris E. D( ES e4.1 ES City. State and Zip: 1 -9193 S414-r-6Aa-n-let-exAV Company: SAS o -r Phone number: Confirmation number. Arrival date: a tvggel-1 a I ao ax or alternate number: Departure date: ktfteCH 9 e2011- Relation to cardholder: El Relative 0 Friend Enusiness Associate 0 Other I understand that should there be any issues with the credit/debit card being wed to settle my charges, I will be responsible for all expenses incurred during my gay. Departure date cannot be extended unless a nevi authoriranon form is completed. Guest name: 1, 118w. Guest signature: Date: Rate Information and Approved Charges - Required Room rate:" 4 6") 4 Taxes:* Total daily rate:* Number of nights: ...1— "(Rate and tax amount must be provided by a hotel representative in order to complete this form) a -All Charges 0 Room & Tax 0 Telephone (LD) 0 Telephone (Local) 0 Restaurant O Room SAM/Me K Valet (Laundry) 0 Parking K HS Internet Access 0 Movies K Other: I certify that all information is complete and accurate. I hereby authorize (Marriott Frenchman's Reef 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/debit card listed above. Charges must not exceed I Cow. O4 for the entire stay/event. I understand that a new form will have to be completed if guest wishes to extend MA« May. I ugdfy that I am the authorized signer of the credit/debit card listed Mane. Cardholder name: emoted, Cardholder signature: yrvy lanrew. Y. aMbWillilla c--Ppr2s1 E. ePs-reinl Date: ("9-LDS-- aC)t3- EFTA00313629