Gift Certificate Authorization Form

Gift Certificate Authorization Form S PA 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 t Gift Card Purchases Recipient (As it will appear on theGift Certificate): Melanie Spinella Please Choose ONE of the following options: Services to be Received: Options for Services ONLY: 0 Include Tax (4.3% h7C Service Tat) OInclude Gratuity Please Note: Prices on all Ceremonies. Retreat Packages and Private Spa Suite Services include an 18% gratuity. OR Flat Monetary Amount: Additional Information Special Instructions: Total Value of Gift Card: $2000.00 Delivery Method Please note that we do not ship gift certificates via US Mail. 2 Pick - Up at Spa Reception No Charge FedEx II Fed Ex Next Day: $35.00 0 Fed Ex Second Day: $14.00 0 Own Fed Ex Account Number. Messenger Manhattan Only Not available on weekends 0 $15.00 Messenger 9AM —5PM Weekdays ONLY • $30.00 Messenger After 5PM Wekkdays ONLY Ship to: • Recipient 0 Purchaser • Third Party Name: Address: City. State and Zip: Cardholder Information Name as it appears on the credit card: Jeffrey Epstein Type of Card: 0 Visa 0 Mastercard 2 American Express 0 Discover Account Type: Account Number. Address (Billing Address): GA IT ST City, State and Zip: NE( ) yO,CiC. /OOe I Phone Number. "i.So - c Fax or Alternate Number: El Corporate Company Name: F:xp. Date: 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 note that we require a handwritten signature in order to process this order. - - Cardholder Name (Please p • 0: Cardholder Signature: Gps-re,,J Date: Thee / 4- aerr EFTA00314151