DS9 Document EFTA00313786

B THE BREAKERS PALM .EACH CREDIT CARD AND CITY LEDGER AUTHORIZATION FORM I j r---,FFAGN PST hereby authorize The Breakers Palm Beach, Inc. to collect payment for the following charges (only items that are checked), by processing a charge to the credit card or city ledger account listed below. Room and Tax Parking Incurred by: From (date): Food and Beverage y All Charges 564s to) 004-or to Reservation Confirmation Number: Bungalow Card Type: Visa Amex MC Diners Discover: JCS: Account Type: /Individual (personal credit card) Corporate (Company Name) Credit Card #: Expiration Date: CIV (Security Code): City Ledger # (Club Members): (34 digits found m the face or at the back of the credit card) Driver's License #: (Required if paying by credit card) Cardholder's Name: Cardholder's Address: (2. t f<S-r ► IOO~I Cardholder's Phone Number: Cardholder's Email Signature: Date: a --Please note that this authorization is n valid for any type of "Debit" card-- Please return form via email t. sender or fax to 561-659-8403 **Please include a photocopy of the front and back of Credit/Membership Card** EFTA00313786