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Authorization For Billing to 3rd Party Credit Card

Please fill out the form below, print and fax a clear photocopy of the front and back of the credit card that is to be billed to xxx-xxx-xxxx.

Name of Guest:
Reservation Number:
Arrival Date:
Number of Nights:
Name of Card Holder:
Mailing Address of Cardholder:
Telephone Number:
Fax Number:
Credit Card Number:
Expiration Date

 

Charges To be Billed: (Please Select An Option Below)

	ROOM AND TAXES
	ROOM , FOOD AND TAXES
	ROOM , FOOD , GAS  AND TAXES
	CAR  REPAIRES
	Other: (Please Specify)

 

I the undersigned, hereby Authorize to bill the above charges to my credit card which appears above. I have attached a clear photocopy of the front and back of this card. I accept that by guaranteeing the room, and that I am also taking responsibility for the room and will be held liable for any damages that may occur while occupied by my guest.

Signature of Cardholder: _____________________________________ Date _________________