CLAFkl DGE'S Credit Card Authorisation for Payment Form Guest Name Ms Karyna Shuliak Confirmation No. 20U6PF Arrival Date / No. of Nights 18t April 2016 for 3 nights Room Type Deluxe King Room Rate Details GBP 650 (GBP 780 inclusive of 20% VAT) rates are per room per night, exclusive of breakfast and subject to a discretionary service charge (5%). I authorize the below marked charges associated with the above guest to be charged to the following credit card In my absence and hereby Instruct the credit card company to honor any charges presented. Please tick one box as appropriate, to confirm what charges will be accepted on your card. Room Charges. VAT Room Charges. VAT & Service Charge Room Charges. VAT, Service Charge & Breakfast NI Charges (Cash advances we not to pad out %pins* this card) IMPORTANT NOTE: In order or us to ensure that we manage your credit card data securely, please provide the full credit card number over the phone and not on this form, using the telephone number below: +44 (0)20 7107 8842 Credit Card Type: Ama Please do NOT write in this section _____ . Credit Card Last Four Digits Of Embossed Nr. 3 O O / Issuing Bank: Lirt( eft/tam exPe CS Credit Card Expiry Date: a 1 /6 Cardholders Signature: ( 2 Full Name (in capitals), as it appears on your card ,f ITT A', r... V e / ) ...0 2_4T'; "--/ Date: Hi/47/6 ass: House or Flat Name (or number): 9 Street: 54- .5. 7 7/.s'1 S4 /2.6 6 r — Cily and County/State: AJ eza (to 2 K , A..) L.1 . - . Postal Code/Zip Code: /O0 .2_ / Landline Telephone Number et ; / 1 7S-.O - 9 P 9J- Country: te ,gl 4. Please indicate by ticking the box below if you would like to receive a copy of your settled charges By post to the address you have provided By email to the following email address: Upon receipt of this document and before the requested service can be provided the Credit Lard supplier will be contacted and verification sought where possible. Where verification is not possible. we reserve the right to seek authorisation to the value of f0.01. Should any of the details not correspond with those held by the Credit Card supplier or authorization is not approved; this form will not be accepted. This card will be pre-authorized three days prior to your guest's arrival. Please be aware that your guests will be asked for payment directly should we be unable to obtain payment from the card detailed above for any reason. Please email the completed form to: reservationseclaridoes.co.uk Authonscd OnStre by: EFTA00316214