DS9 Document EFTA00306067

LIFE Dear Sir/Madam. Life Hotel 19 West 31* Strest, New York NY 10001 Credit Card Authorization Form This form has been created in order to allow you to have third party expenses charged to your credit card. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please sign and date the fo c fax the completed form along with a copy front and back of your credit card and ID C0(212)615.9901 or e-mail it to Cardholder Information Name as it appears on the credit card (ItegoIred):JG Ce Eps re Card typc(Requlred): Account type(RequIred): Account number(Required) Address(Required): (where statement is mailed) City. State and Zip(Required): N e.t.a CrOg Phone number(Required): Bank Phone number on the back of the card (Required): Individual (personal credit card) U Corporate I Company Name: .9 ea-ft, 7/ s.e. NY (°°2f mate number. For internal use only: Dote! )'erification: Date Employee ID: Guest Information Guest name(Requlred): Company: Phone number(RequIred): Fax Of alternate number. Confirmation number(Requlred): Arrival date(Required): Departure date(RequIred): Relation to cardholder(Required): O Relative K Friend Rale Information and Approved Charges Room rate: ID Business Associate D Other. Taxes and 14.75% plus Total daily rate: Number of nights. fees: $3.50 plus S25 city fcc All Charges Li Room & Tax Valet (Laundry) U Parking Other: D Telephone (LD) D Telephone (Local) K Internet U Movies LI Restaurant certify that all information is complete and accurate. I hereby authorize Life Hotel to collect payment %r all charges as indicated in the Rate Information and Approved Char season of this form by orornsine a ohmic to the c dill card listed above. Charges MUSI not exceed for the enti )e caliph:red if guest wishes to extend his/her nay. I certify that I am the authorized si Cardholder name: (Primed) Cardholder signature:  r F FP-CY `cabrF A-1 Date: Ore ° Gj If ALL required information is not filled in the authorization will not proceeded bel EFTA00306067