LIFE wore. Life Hotel * 5 q 19 West 31° Street, New York NY 10001 Credit Card Authorization Form Dear Sir/Madam, This form has been created in order to allow you to have third party expenses charged to your credit card. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please sign and date the form be ¢ fax the completed form along with a copy front and back of your credit card and ID to (212) 615.9901 or e-mail it to . Cardholder Information JEFFREY EPR STE TY Name as it appears on the credit card (Required): Card type(Required): Account type(Required): Individual (personal credit card) Company Name: QO Corporate Account number(Required) Address(Required) (where statement is mailed) GER T/ 54 Mew "ORK Phone number(Required): jcrmate number: City, State and Zip(Required): Bank Phone number on the back of the card (Required): For internal use only: Hotel Verification: Date Employee ID: Guest Information Guest name(Required). : - £ Company: Phone number(Required): Fax or alternate number Confirmation sumber(Required): Arrival date(Required). Departure date(Required). Relation to C) Relative () Friend (L] Business Associate () Other cardholder{Required): Rate Information and Approved Charges Room rate: Taxesand 14.75% plus Total daily rate: Number of nights: fees. $3.50 plus $25 city fee All Charges Room & Tax Telephone (LD) Telephone (Local) Restaurant 8 Q) Valet (Laundry) QO Parking () Intemet Q Movies O Other. I certify that all information is complete and accurate. I hereby peeareniees Life Hoael to collect payment for all charges as indicated in the Rate Information and Approved Charg: edit card listed above. Charges must not exceed i complcted if guest wishes to extend his/her stay. I Cardholder signature = PTE ho om g/ OG | (es &§ If ALL required information is not filled in the authorization will = = processed certify that I am the authorized sif Cardholder aame: (Printed) EFTA00306067