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Credit Card Authorization Form

This document is a credit card payment authorization form for a hotel. It requests the cardholder's name, credit card number, expiration date, and security code to charge an amount for an unspecified service. The form provides instructions for the cardholder to fill out the form, sign it, and fax it along with a copy of their credit card and passport.

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Agustinus Agus Purwanto
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© Attribution Non-Commercial (BY-NC)
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3K views2 pages

Credit Card Authorization Form

This document is a credit card payment authorization form for a hotel. It requests the cardholder's name, credit card number, expiration date, and security code to charge an amount for an unspecified service. The form provides instructions for the cardholder to fill out the form, sign it, and fax it along with a copy of their credit card and passport.

Uploaded by

Agustinus Agus Purwanto
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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Hotel Logo

CREDIT CARD PAYMENT AUTHORIZATION


I, authorize _________________________________________________________________________________________ __________________________________________________________________________________________________________________ ______________________________________________________________________________________ to charge the sum of :

(please indicate currency)


(in letters)

TO:
Visa Master Card Amex Discover JCB Diners Club

Card Number :

Expiry Date:

Please fill in the last three-digit number (for VISA card) or four digit number (for AMEX) appearing on signature panel: (see example)
My name as appear on the card is : The above mentioned charge is for :

Card Holder's Signature :

Date: Cardholder's Passport No : Cardholder's Address :

Cardholder's Tel. No : Cardholder's Fax No :

Country Code Country Code

No No

Instructions on How to Use This Form: 1) Kindly fill your credit card type, card number, name on card, expiry date, plus the last 3 or 4 digits on the back of your card (depending on your card type) 2) Print out the form and verify that all details are correct, then please sign your name on the "Card Holder's Signature" line 3) Fax authorization form, along with copy of the credit card on both sides to Reservation Dept at Telp: (000) 0000000 4) Please also fax a copy of your passport (the page with picture and passport holder information)

American Express 4 digits on front of card

Visa and Master Card last 3 digits on back of card

The card Identification Number (Card ID) is required for American Express, Visa and Mastercard. The Card ID is an added security feature to help protect you against online fraud.

The card Identification Number (Card ID) is required for American Express, Visa and Mastercard. The Card ID is an added security feature to help protect you against online fraud.

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