DS9 Document EFTA00293606

It MARRIOTT Third Party Credit Card Authorization Form This form has been created in order to allow you to have third party expenses charged to your credit/debit card. I understand that the hotel is not required to accept this form and the guest should check with the hotel to ensure they accept third part transactions. Please provide all the information requested below to ensure prompt processing of your a m mlication. We ask ou to lease sign and date the form before submission. Please send the completed form to Minsk Marriott Hotel by e-mail: FOR SECURITY reasons, Marriott International conforms to all Payment Card industry (PCI) standards. However, we recommend that the credit card holder purchase a gift card for the guest (if possible) rather than send their credit card number via this third party form. CARDHOLDER INFORMATION - Required Name as it appears on the credit/debit card: Card Type: K Visa K MC Account Type: K Individual - K Debit / K Credit K Corporate - Company Name: Issuing Bank: Phone: Account Number: Exp. Date: Address (statement): City, State, Zip: Phone Number. Fax or Alternate Number: GUEST INFORMATION - Required Guest Name: Address: City, State, Zip: Company: Phone Number. Fax or Alternate Number: Confirmation Number: Arrival Date: Departure Date: Relation to Cardholder: K Relative K Friend K Business Associate K Other I understand that should there be any issues with the credit/debit card being used to settle my charges, I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed. Guest Name: (Printed) Guest Signature: Date: RATE INFORMATION AND APPROVED CHARGES - Required Total Amount: K All Charges K Room & Tax K Telephone (LD) K Telephone (Local) K Restaurant K Room Service K Valet/Laundry K Parking K HS Internet Access K Movies K Other I certify that all information is complete and accurate. I hereby authorize Minsk Marriott Hotel 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 S 153 for the entire stay/event. I understand that a new form will have to be completed if guest wishes to extend his/her stay. I certify that I am the authorized signer of the credit/debit card listed above. Cardholder Name: (Printed) Cardholder Signature: Date: PLEASE DO NOT SEND A PHOTOCOPY OF THE FRONT OR BACK OF YOUR CREDIT CARD. Marriott Cerdidential and Proprietary Inbrrnabon EFTA00293606