Credit Card Payment Authorization Form
Please complete all areas below. Incomplete requests may be rejected. This form must be received at least 5 business days prior to the Check-In, or by specified date in Event Contract, to ensure acceptance of the credit card to be charged.
Do not send completed form by email.
FAX COMPLETED FORM TO: _______________________ATTN: ____________________________
HOTEL USE ONLY: Date:
Authorized Amount: Approval Code: Date:
CARDHOLDER - Please complete the following section and sign/date below.
Guest / Group Name: ……………………………………………………………………………………………………
Check-In / Event Date: ………………………………………………………………………………………………….
Name of Person/Group Making Reservation: Phone: ………………………………………………………………….
Cardholder Name as it appears on Credit Card: …………………………………………………………………………
Cardholder Billing Address: ……………………………………………………………………………………………..
City: ………………………. State: ……………………….. Postcode: ……………………………………………..
Daytime /Business Telephone: …………………….. Evening Telephone: …………………………………………….
Credit Card Number:……………………………………..Expiration Date: …………………………………………..
Credit Card Type: (Circle one) Visa/Master Card American Express Discover JCB Diners Club
Credit Card Issuing Bank Name: ……………………………………………………………………………………….
Bank Phone Number (from back of your credit card): ………………………………………………………………….
I agree to cover the following categories of charges: (Please circle)
All Charges Room & Tax Food & Beverage Retail Recreation