Hotel Address

Direct Bill Authorization Form

Guidelines

This application is required in order to extend credit to your

company/organization.
Hotel Name requires that applicants complete all fields of the Credit Application.
Additional credit reference information from your company may be submitted in
addition to completing this form.
Hotel Name requires a minimum of four (4) positive credit references specifically from
hotels.
References should be listed only if the hotel has been used within the last 12 months from
the date of application.
References must include the hotels contact information and the dates of the last stay.
The Hotel and the Client (company/organization) agrees and understands that this
application is to obtain credit with the Hotel and if the Hotel extends credit to
said company/organization that these terms are binding herein.
The enclosed information is for the purpose of obtaining credit and is warranted
to be true. As an authorized agent of said company/organization the Client
authorizes the Hotel to process all references listed pertaining to their credit
worthiness and financial responsibilities.
The undersigned/company/organization authorizes all charges and agrees: to process
all invoices received in a timely manner and pay within a 30 day period, to pay
any fees associated with returned checks (minimum Rs.), to pay a 10% late fee
on the outstanding balance should the account reach 31 to 60 days past due, 20%
late fee on the outstanding balance should the account reach 61 - 90 days past
due and 25% late fee on the outstanding balance after 90 days. Any payments
received shall be applied first against such late charges.
The undersigned/company/organization agrees to notify the Hotel of any change in
ownership, change in address, or change in the financial ability or inability to pay
invoices in a timely manner. It is also agreed that the financial statements (to be
kept confidential) be supplied upon request to Hotel for reevaluation of credit
worthiness.
An active credit card will be placed with this account for guarantee purposes
only. If credit card information should change the Hotel will be notified and a
new credit card authorization form will be executed and sent. If terms of this
agreement are not met the hotel reserves the right to charge the outstanding
balance to the credit card on file and charges will not be disputed.
The Hotel reserves the right to: withdraw, suspend, or place on probationary
notice the direct billing facility at any time without notice.

Company/Organization Information
Legal Name ____________________________________________________________________
Trade Name ____________________________________________________________________
Division _______________________________

Type of Business ______________________

Address _______________________________________________________________________
City ________________________

State _____________________

Telephone Number ________________________

Zip ______________

Fax Number _________________________

Email ________________________________________________________________________
Address is:

Branch

How long at address ___________

address

Head Office

Regional Office

National Headquarters

If less than one year in state, please provide previous

Parent Company
Address _______________________________________________________________________
City ________________________

State _____________________

Telephone Number ________________________

Zip ______________

Fax Number _________________________

Email ________________________________________________________________________
Proprietorship

Corporation

Partnership

LLC

Other

Proprietorship: Owners Name _____________________________________________________

Address _______________________________________________________________________
City ________________________

State _____________________

Telephone Number ________________________

Zip ______________

Fax Number _________________________

Corporation/Partnership/LLC: State in which incorporated _______________________________

Date of incorporation __________________________________________
Exact Corporate Name (if different from trade name) ___________________________________
**ATTACH COPY OF ARTICLES OF INCORPORATION

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Partnership: Complete the following information for each partner (attach a list if necessary)
Name _________________________________________________________________________
Address _______________________________________________________________________
City ________________________

State _____________________

Telephone Number ________________________

Zip ______________

Fax Number _________________________

Principals/Corporate Officers
President, Vice President, Secretary, Treasurer, Chief Financial Officer
Name
Title
Telephone Number
Name
Title
Telephone Number
Name
Title
Telephone Number
Name
Title
Telephone Number
Name
Title
Telephone Number

Bank Details
Bank Name ____________________________________________________________________
Bank Officer ___________________________________________________________________
Branch & Address _______________________________________________________________
Address _______________________________________________________________________
City ________________________

State _____________________

Telephone Number ________________________

Zip ______________

Fax Number _________________________

Email ________________________________________________________________________

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Account Number ________________________________________________________________

**PLEASE ATTACH A VOID CHEQUE
IFSC Code (NEFT/RTGS)
SWIFT Code
PAN Number
Service Tax Regn. No.
EXCISE REGN No.
Excise tax indicator vendor
SSI status
LST No./ VAT No
CST No.
Is the company exempt from tax?

Yes

No

**ATTACH A COPY OF THE TAX EXEMPTION CERTIFICATE

Hotel References
Name _______________________________________________

Date of stay _____________

Address _______________________________________________________________________
City ________________________

State _____________________

Zip ______________

High Balance _____________________________

Date of stay

________________________

Telephone Number ________________________

Fax Number _________________________

Email ________________________________________________________________________

Name _______________________________________________

Date of stay _____________

Address _______________________________________________________________________
City ________________________

State _____________________

Zip ______________

High Balance _____________________________

Date of stay

________________________

Telephone Number ________________________

Fax Number _________________________

Email ________________________________________________________________________

Name _______________________________________________

Date of stay _____________

Address _______________________________________________________________________
City ________________________

State _____________________

Zip ______________

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High Balance _____________________________

Date of stay

________________________

Telephone Number ________________________

Fax Number _________________________

Email ________________________________________________________________________

Name _______________________________________________

Date of stay _____________

Address _______________________________________________________________________
City ________________________

State _____________________

Zip ______________

High Balance _____________________________

Date of stay

________________________

Telephone Number ________________________

Fax Number _________________________

Email ________________________________________________________________________

Special Billing Instructions: _______________________________________________________

Contact Person from A/P: _________________________________________________________
Telephone Number ________________________

Fax Number _________________________

Contact Person for Reservation Authorization _________________________________________

Telephone Number ________________________

Fax Number _________________________

Persons authorized to place reservations

Name

Telephone

Are guests allowed to make their own reservations?

Yes

No

Will you reimburse Hotel Name for guaranteed No Shows?

Yes

No

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This form was completed by _______________________________________________________

Date ________________________________
This form was approved by________________________________________________________
Owner/Principal Officer Signature __________________________________________________
Date ________________________________
The information on this form is true and correct and is voluntarily provided to assist Hotel Name
in establishing a commercial credit account for the within named company. Hotel Name or its
agent is authorized to obtain and verify credit and financial information from any and all
references. It is expressly understood that if credit is approved, all charges will be paid on all
past due amounts, that in the event of default collection costs, attorneys fees and any costs of
litigation or arbitration will be reimbursed to Hotel Name, and that the company contact hereon
will be responsible for all charges until Hotel Name receives notice in writing of sale or
termination of company or business
PERSONAL GUARANTEE OF CORPORATE ACCOUNT
As a condition of credit being extended to the within named corporation, the undersigned does
hereby personally guarantee payment of all charges until this guarantee has been revoked in
writing by that respective guarantor, and written revocation has been received by Hotel Name.

Signed ________________________________________________________________________
Address _______________________________________________________________________
City ________________________

State _____________________

Zip ______________

Telephone Number ________________________

Alternate Number _____________________

Email __________________________________

Fax Number ________________________

Date signed __________________________

Applicant understands that it is waiving any right it may otherwise have had to litigate outside
the jurisdiction where the hotel accommodation is extended, and charges incurred. Application
for credit is hereby made and the above references given. It is understood that this information
will be held in strictest confidence and used only by our management department. Applicant
understands that Hotel Name is not obligated to offer direct billing services under this account
unless and until the hotel management has notified them that the direct billing services have been
approved.

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I hereby authorize Hotel Name to verify the above mentioned information

Name _________________________________________ Signature ______________________
Title __________________________________________

Date

________________________

I _____________________________________________
charge my
(Name as it appears on the credit card)

hereby authorize Hotel Name to

credit card the entire outstanding balance in the event that _______________________________
(Company Name)
Account reaches 30 days past due.

Visa

Master

American Express

Credit Card Number _____________________________________________________________

Expiry Date ________________________________
CVV Number ______________________________
Authorizing signature _________________________________

Date ___________________

Authorizing signature _________________________________

Date ___________________

**PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE CREDIT CARD

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For office use only

References checked by _____________________________________

Date ______________

Comments: ____________________________________________________________________
Direct Bill approved by_____________________________________

Date ______________

GM Signature __________________________________________________________________
Renewal Date _________________________________________ Credit Limit ______________
Direct Bill account number (AR #) _______________________

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