Title: Microsoft Word - credit_card_payment_authorization_form IAP.doc
Author: Mac
Last saved by: Joseph Gendron

_Credit _Card _Payment _Authorization _Form

_Do _not _send _completed _form _by _email.

_FAX _COMPLETED _FORM _TO:  	

_ATTN:  	

_Date:   	

HOTEL USE ONLY:
Guest / Group Name: Check-In / Event Date:
Name of Person/Group Making Reservation: 	Phone:
Authorized Amount: 	Approval Code: 	Date:

CARDHOLDER - Please complete the following section and sign/date below.
Cardholder Name as it Appears on Credit Card: Cardholder Billing Address:
City: 	State: 	Zip:
Daytime /Business Telephone: 			Evening Telephone: Credit Card Number: 			Expiration Date: Credit Card Type: (Check one) 	☐ Visa 	☐ MasterCard
☐ ^American ^Express	☐ ^Discover	☐ ^JCB	☐ ^Diners ^Club 
_Credit _Card _Issuing _Bank _Name:  ______________ _Bank _Security _Number _(from _back _of _your _credit _card): ________________________

I agree to cover the following categories of charges: (Please check)
☐ All Charges 	☐ Room & Tax 	☐ Food & Beverage 	☐ Retail 	☐ Recreation

_I _agree _to _cover _the _above _categories _of _charges _up _to _a _Maximum _Amount _of _$  	

Note: Charges for room and tax, group deposits or direct bill account payments will be charged to your credit card immediately. Any incidental charges circled above will be charged at the time of check-out.

_Amount _to _be _immediately _charged _to _credit _card _for _room _and _taxes _or _deposit: _$ 	

_Final _Balance _Billed _to _Credit _Card _(hotel _use _only): _$ 	

By signing below, you authorize the hotel to charge your credit card immediately for the amount indicated above up to the “Maximum Amount” indicated above. You further acknowledge that if “all charges” has been selected, then all guest/group related charges  (less Deposit) will be charged to the above card number at the time of checkout or event conclusion.

Cardholder Signature:                                                                                                                                          Date: