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TIIE Ruh [ -t I NI* Credit Card Authorization Form II '711C. In Dear Guest, This form has been created in order to al loo you to have third party expenses charged to your credit cant Please pnnide all the information requested below to ensure prompt processing of your application. We ask yo r i the form before submission. Please fax the completed form to the attention of Front Office. fax Cardholder Information Name as It appears on the credit card: j --- rit'seGNI eps-r-g.ii.1 Card type: CI Visa El MC Ea Amen Account type: Cr Individual (personal) U DEBIT CARD Cagsturr CARD D Corporate I Company Name: Account number. Address: ,.hat ass.. install City. State and Zip: Exp. date: C- I I L= AST M ST SITA :11--> r ELJ • Phone number: Fax or alternate number: Goat 'reformation -PHILAwe \JA ),A Guest name: Company: Phone number: Confirmation number. Arrival date: Relation to cardholder: Fax or alternate number Fa or. I Separture date: a - fiusiness Fe6 JO. CI Relative CI Friend Associate lj Other. K Dblersial U Discover JCR Rate Information aid Ammpved_Chantes Room rate: *(Rate and tax amount must be provided by a hotel representative in order to complete this form) ~AIICharges CI Room & Tax j Telephone (LD) K Telephone (Local) CI Restaurant j Room Service lj Valet (Laundry) U Parking U HS Internet Access j Movies X Other: Taxes:* Total daily rate:* Number of nights: I catty that all internal= is compkic trel tannic. I tetchy audacity Ibt etka-Carleat Sr. Means to <aka symere tot ell chutes as imitated in Ste Sae letcoccelion led Apprond Charges season of this form by lactates a charpe tomecraht cad listed above. °sopa must not exccoi cc foe the entire ststy.ttast I unearned ant a new form sall ten to be complesed If typal wishes to exited hostler say I and) that 1 in the embolued arm of the =ducats' hissed abuse. Cardholder name. memo Cardholder signature: 7 Tbab4......."C••••••.L LC -am • Ni. 2, Date: jc- eP) . Ts a-or+ EFTA00313628