Dear Sir/Madam,

This form has been created in order to allow you to have third party expenses charged to your credit/debit  card. 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  	. Do not send photocopy of the front or back of the credit card with this form, as this is against credit card company regulations.

Cardholder  Information  - Required
Name as it appears on the credit/debit  card:

Card type: 	Visa 		MC 	Amex 	Diners/CB 	Discover 	JCB Account type: 	Personal 	Corporate | Company Name:
Issuing Bank: 	Phone #: Account number: 	 Exp. Date:
Address:
(wh ere statement is mailed)	 	
City, State and Zip:	 		 Phone number:	 	Fax or alternate number:     	

Guest Information  - Required
Guest name:	 	 Address:
City, State and Zip:	 	 Company:
Phone number:                                                                                    Fax or alternate number:                                                   

Confirmation  number:                                                                                                                                                                       Arrival date:                                                                                         Departure  date:                                                                    Relation to cardholder:                 Relative                   Friend                    Business Associate                  Other:
I 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:                                                                                                                           Date:                                                         

Rate Information  and Approved Charges  - Required

Room rate:*   	  Taxes:*   		Total daily rate:*   	 Number of nights:  	

*(Rate and tax amount must be provided by a hotel representative  in order to complete this form)

All Charges	Room & Tax	Telephone  (LD)	Telephone (Local)	Restaurant	
Room Service	Valet (Laundry)	Parking	HS Internet Access	Movies	
Other:					

I certify that all information  is complete  and accurate.  I hereby authorize  Marriott Hotel 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  	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:    (P rinted)

Cardholder signature:	 	Date: