DS9 Document EFTA00313800

II] DORAL INN & SUITES Third Party Credit Card Authorization Form This form has been created in order to allow you to have third party expenses charged to your credit/debit card. I understand that the hotel is not required to accept this form and the guest should check with the hotel to ensure they accept third part transactions. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please sign and date the form before submission. Please fax the completed form to Doral Inn and Suites Miami Airport West at (305) 429 8754 FOR SECURITY reasons. Doral Inn and Suites conforms to all Payment Card Industry (PCI) standards. However, we recommend that the credit card holder purchase a gift card for the guest (if possible) rather than send their credit card number via this third party form. CARDHOLDER INFORMATION - Required Name as it appears on the credit/debit card: Card Type: Account Type: Issuing Bank: Account Number: Address (statement): City, State, Zip: Phone Number. JER-ciac-s•I G €--,-ps-rel,.1 El Visa El MC laikmex 0 Diners/CB 0 Discover Fax or Alternate Numbe GUEST INFORMATION - Guest Name: Address: City, State, Zip: Company: Phone Number: Confirmation Number: - 0 Debit / 0 Credit C-;i24CA 0 Corporate - Company Name: Phone: Exp. Date: gal 0 JCS Relation to Cardholder: 0 Relative Fax or Alternate Number: Arrival Date: TAr.1 3, a5::)11 Departure Date: Tpvti . apt& agend 0 Business Associate 0 Other understand that should there be any issues with the credit/debit card being used to settle my charges. I will be responsible for all expenses incurred during my stay. Departure date cannot be extended unless a new authorization form is completed. Guest Name: (Printed) Guest Signature: RATE INFORMATION AND APPROVED CHARGES - Required Room Rate:* tc,S) , as Taxes:* Total Daily Rate:* *(Rate and tax amount must be provided by a hotel representative in order to complete this form.) ErAll Charges 0 Room & Tax K Telephone (LD) 0 Telephone (Local) 0 Room Service 0 Other Date: 0 Valet/Laundry 0 Parking El HS Internet Access Number of Nights: ID Restaurant 0 Movies I certify that all information is complete and accurate. I hereby authorize Doral Inn and Suites Miami Airport West to collect payment for all charges as indicated in the Rate Information and Approved Charges section of this form by processing a charge to the credit/debit card listed above. Charges must not exceed $5,000 for the entire stay/event. I understand that a new form will have to be completed if guest wishes to extend his/her stay. I certify that I am the authorized signer of the credit/debit card listed above. Cardholder Name: (Printed) Cardholder Signature: r Date: SSAdaaae_ r-P-6 GPSTFirJ Please do no s nd a photocopy of the front or back of your credit card. 1212 NW 82" Avenue. Miami FL 331261 P : (305) 629 8755 / FAX (305) 629 8754 / MAW docalmnandsuites.com /email: cloralinneolsolesegmailcan EFTA00313800