DS9 Document EFTA00313619

SPA Credit Card Authorization Form THE PENINSULA 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. We ask that you either fax this completed form to The Peninsula Spa at (212) 903.3958 or e-mail it to Third Party Payment of Services ONLY Guest Name: gAT ri •4 "RUCE:frtit.--(Eg.. Date of Services: Rate Information and Approved Charges Services: ilvbaysyv..) a, 0,0 -14 Se."4.4,6, FAC..(At___ Rate: 1)E C I 49 ,DA) /C. El Service ONLY 0 Service and 4.5% Sales Tax ONLY latiervice, 4.5% Sales Tax and Gratuity 02 C % 12Additional Services Rendered (i.e. Treatment Upgrades) 0 Products Purchased Maximum Allowable Amount: Please Keep My Form on File For Future Use c) Cardholder Information Name as it appears on the credit card: :Tar r-- Ray e?.s-re_t Type of Card: 0 Visa El Mastercard a --American Express K Discover Account Type: Er Individual (Personal Credit Card) 0 Corporate Company Name: Credit Card Number: Address (Billing Address): OA ST -4-i )t S-r City, State and Zip: N ‘j NY 100Q_1 Phone Number: 'ax or Alternate Number: Expiration Date: r / I certify that all information is complete and accurate. I hereby authorize The Peninsula Spa. New York to collect payment for all charges as indicated on this form by processing a charge to the credit card listed above. I certify that I am the authorized signer of the credit card listed above. Please e that we uire a handwritten signature in order to process this order. Cardholder Name (PI ase print): Tear a-af e-Ps-E(si Cardholder Signature: Date: 1)EC (P an( r EFTA00313619