3627 Central Ave, Hot Springs AR 71913

Phone 501.623.1700 Fax 501.623.1876

CREDIT CARD PAYMENT AUTHORIZATION FORM

Sign and complete this form to authorize Comfort Inn and Suites Hotel to make a one time
debit to your credit card listed below.

By signing this form you give us permission to debit your account for the charges indicated on
or after the indicated date. This is permission for a single transaction only, and does not provide
authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I, ______________________________________, authorize Comfort Inn and Suites Hotel to charge my

Credit Card account indicated below:

CC Number: ____________________________ Expiration: ____________

For the following charges:

Room and Tax All Charges Meeting room

Deposit Only Amount $ ______

Cardholder Name: _____________________________________________________________________

Phone #: (___) _____________________ Fax: (____) ___________________

This payment is for: ____________________________________________________________________

Confirmation Number: _________________________________ Date of Arrival: ___________________

Additional Requests/Comments:
_____________________________________________________________________________________

*** Please contact hotel directly to provide the full credit card number for the reservation if credit card
is not on file already ***

*** Please include a copy of your credit card and driver license, when returning ***

Signature: ____________________________________________ Date: _______________________