400 Avenue of the Champions Palm Beach Gardens Fl 33418
Phone: 561-627-2000 Fax: 561-691-9133
Name of Company / Association / Individual:
This is your authorization to bill my credit card number as follows:
MasterCard Visa American Express Discover
Diners Card Other:__________________________
Card Number: ___________________________________________ Exp. Date : __________________
Name as it appears on card: _____________________________________________________________
Billing Address/Phone:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Room - Tax Resort fee Only Room & Tax, Food & Beverage All Charges
All Charges Others: ____________________________________________
List Name (s) of Guests ( if applicable ):
___________________________________ ______________________________________
___________________________________ ______________________________________
___________________________________ ______________________________________
Arrival Date: ________________ Departure Date: __________________
_______________________________________ __________________________________
Cardholder’s Signature Date
** We must receive a copy of the front & back of the credit card being used along with this form. Thank you.