MANDARIN ORI Al NEW YORK 3rd PARTY CREDIT CARD AUTHORIZATION GUEST NAME: FROM: TREATMENT: DATE OF TREATMENT: TIME OF TREATMENT: I hereby authorize Mandarin Oriental, New York to charge my credit card for the charges indicated below for the above guest: Cardholder Last Name Cardholders First Name Credit Card El Amex ❑ Visa Exp. Date 0 MasterCard ❑ Diners I 0 JCB ❑ Discover Billing Address City Telephone State Zip Country Fax Email Ainolint S Approval Code: Item purchased lalso, state quantity): I assume responsibility for the above charges. Please sign Kindly fax to to the attention of Mandarin Oriental, New York Spa Please check off the following: For Office Use only: _ Copy for Guest Processed by: Date: u Copy for Spa o Copy for Finance (lW) EFTA00286342