EFTA00313780.pdf

THE BREAKERS PALM if ACH CREDIT CARD AND CITY LEDGER AUTHORIZAT ION FORM I Tr Ft= (2-g-`1 PP S11 I td hereby authorize The Breakers Palm Beach, Inc. to collect payment for the following charges (only items that are checked), by processing a charge to the credit card or city ledge r account listed below. Room and Tax Food and Beverage Bungalow Parking All Charges Incurred by: From (date): until (date): H0 of . Reservation Confirmation Number: Card Type: Visa Amex Discover: MC Diners JCB: Account Type: /Individual (personal credit card) Corporate (Company Name) Credit Card #: Expiration Date: CIV (Security Code): (3-4 digits found on the face or at the bock of the credit card) City Ledger # (Club Members): Driver's License #: On cocas -12.7-,71- (Required if paying by credit card) Cardholder's Name: PEREN Ps—rOst.1 Cardholder's Address: 9 tiips—r 44-( ST.. m\1 10021 Cardholder's Phone Number: Cardholder's Email Signature: Date: SPapep. --Please note that this authorization is valid for any type of "Debit" card--- Please return form via email t sender or fax to 561-659-8403 **Please include a photocopy of the front and back of Credi t/Membership Card" EFTA00313780 AMERICAN EXPRESS EFTA00313781 EFTA00313782