DS9 Document EFTA00313627

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 r nested bed w to ensure prompt processing. We ask that you either fax this completed form to The Peninsula Spa at e-mail it to Third Party Payment of Services ONLY Guest Name: KAT H y gAEfrok--(Ere Date of Services: C 19a-0 /S Rate Information and Approved Charles Services: Mani (--) e r t n,tt SeetAA R4C(4_ Rate: El Service ONLY El Service and 4.5% Sales Tax ONLY Olervice, 4.5% Sales Tax and Gratuity op-Q % 12r--Additional Services Rendered (i.e. Treatment Upgrades) K Products Purchased Maximum Allowable Amount: 411. CRO 0 , Q O Please Keep My Form on File For Future Use K Cardholder Information Name as it appears on the credit card: Creir r-- Type of Card: O Visa O Mastercard ErAmerican Express 9 Discover Account Type: a Individual (Personal Credit Card) El Corporate Company Name: Credit Card Number: _ Expiration Date: r / ic, Address (Billing Address): Qj CA -TT ST • City, State and Zip: WI N'( / 00Q-‘ Phone Number: Fax or Alternate Number: G- ?es-relit-1 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 ie that we tire a handuritten signature in order to process this order. Cardholder Name (Pl ase print): Pg-e•f PP.S-r Cardholder Signature: Date: -1-)E_C I) an( r EFTA00313627