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THE MARK CREDIT CARD BILLING AUTHORIZATION FORM GROUP GUEST INFORMATION COMPANY/CROW NAME: CONTACT NAME LET L e-1 GI go INDIVIDUAL GUEST INFORMATION GUEST NAMES ARRIVAL DATES DEPARTURE DATES 'RCN`) f5Riase-T- oat, (- .z0 lc trT. ap CHARGES TO BE BILLED (please indicate by marking an X in the appropriate boxes below) CHARGES [ I CATERING ANO MEETING CHARGES [ I GUEST ROOMS & TAXES (I CRP ROOM DEPOSITS< AMOUNT S [ I GUEST INCIDENTALS [ I CATERING DEPOSITS: AMOUNT S I OTHER (Descriplicmp PLEASE NOTE THAT Ural RECEIPT OF THIS FORM THE CREDIT CARD WILL ISE CHARGED FOR THE FULL AMOUNT OF ROOM AND TAX. IF YOU on TO COVER AU. CHARGES. THE INCIDENTAL CHARGES WILL IE. SETTLED UPCN CHECKOUT OF THE GUEST. CARD HOLDER INFO CARD NUMBER: EXPIRATION DATE: NAME AS IT APPEARS ON CARD: Se p": a El c E-93-re N CARD BILLING ADDRESS: CITY: 11/4E/ ‘i TELEPHON EMAIL q EAST I t Sr STATE AND RIP CODE: N y I 00;:> PAX: Oc- [ I AMERICAN EXPRESS [ I VISA [ I MASTER CARD ( I DINERS CLUB ( I DISCOVER [ I ICE I HEREBY AUTHOR/2E THE MARX HOTEL TO USE THECREW CARD INFORMATION PROVIDED ON THIS FORM EITHER AS PAYMENT FOR THE CHARGES DESCRIBED ABOVE I AM AWARE SUPPORTING DOCUMENTATION WR.L ACCOMPANY AU. (MARLS BY SIGNING BELOW I AGREE 10 PAY MY CREME CARD r Tat-1,14k CHARGES AGREED TO ABOVE IN ACCORDANCE WITH MY CARDHOLDER AGREEMENT. CARD HOLDER'S SIGNA DATESIGNED: SE -P tee° PLEASE AlTACH:1) A LEGIT E P#IOTOCOPY OF PROOF OF IDENTIFICATION 2) FRONT AND BACK 0 THE CREDIT CARD YOU WISH TO CHARGE as East y/1h &Tett. New Yolk NY wen USA Tel: au-ma-coo Fax: sexo6-3toa EthiallinHinthalifttliESABFAMBSSIS - www.lhelnarkhnlel Cara Toll free reservations: 1-866-744-4300 EFTA00311423 ../ v EFTA00311424