MPTON®

MPTON® hotels & restaurants Credit Card Authorization Form I :TER--12 el gera.1 hereby authorize Hotel/Restaurant Name to process the following credit card: 3i-oe F jjM6EK froa Guest Name: Confirmation #: Arrival Date: fr lAeCk) Departure Date: A-4 A ito fl `29 , Contact Name: Name on Credit Card (if different from above): c ) E r PPG- y a • IZ Psi-re0J Last Four Digits of Credit Card Number. 3 0 0 ) **To protect your confidential information, do not provide the fidl credit card number in this form. Please CALL the hotel to provide your full credit card number. ** Expiration Date: Billing Address: City/State/Zip: WI 4, ell GAIT Sc 1O0a1 i 0 Daytime Phone Number: Email Address: Authorized Signature: Please Indicate Billing Instru "on errs;l:eck all that DBanquets EAudio Visual Only Ddvance Deposit of S oom and Tax Only cidentals Only nOther (please specify): ** Please note that if a different form of valid payment is not received at :me of check-in, all charges will be applied to the above credit card.** EFTA00317357