1601 Belvedere Road

West Palm Beach, FL 33406

561-689-6400
Credit/Debit Card Authorization Form
Function/Arrival Date:
Name
Dear Sir/Madam,
Please provide all the information requested below to ensure prompt processing of your request to charge
your credit card for the charges indicated below. We ask you to sign and date the form before submission.
The form can be faxed to 561-683-7150 or emailed directly to your hotel representative.

Cardholder Information - Required

Name is it appears on the card:
Card Type:

Visa/MC

Amex

Diners/CB

JCB

Issuing Bank:

Discover
Phone number:

For security purposes, please enter the last 4 digits of the card only:
(a representative will contact you directly for the full credit card number)
Expiration date: _______________
Address (where statement is mailed):

Primary phone:
Primary Fax:

Cellular:
Alternate:

Email Address:
If you are using a company card, please complete the information below:
Corporate/Company Name:___________________________________________
Address (cannot be a PO Box): ________________________________________
City: _____________________________
State:______________

Zip Code: ___________

Phone Number with Area Code: ___________________________________

Authorized Printed Name_________________________________________
Authorized Signer's Business Title: __________________________________

Updated 11/9/2015

Cardholder - Rate Information and Authorized Charges

Guest or Function Name:

Arrival Date:
Departure Date:
Room Rate:

Confirmation #
Room and tax only?

Incidental Charges (Circle approved charges):

All Charges
Room Service
Guarantee only?

Function Charges (Circle approved charges):

Meeting Room Rental

Phone

Internet

Restaurant

Laundry

Rooming List Attached

Banquet Food and Beverage

Other: _________________________________________
Deposit $_______________________________________
Total charges not to exceed $_____________________
I certify that all information is complete and accurate. I hereby authorize EMBASSY SUITES WEST PALM
BEACH to collect payment for the charges as indicated in the Rate Information and Authorized Charges
Section of this form by processing charges to the credit/debit card listed above. I understand that a new form
will have to be completed if the guest wishes to extend his/her stay. I certify that I am the authorized
signer of the credit/debit card listed above.
Cardholder name (printed):
Cardholder signature:
Date:__________________

Guest Information - Required - Identification will be required at check in

Guest Name:
Guest Address:
City, State, Zip:
Primary Phone:
Email Address:

Updated 11/9/2015

Cellular Phone: