THE MARK CREDIT CARD BILLING AUTHORIZATION FORM GROUP GUEST INFORMATION COMPANY/GROUP NAME: CONTACTNAME {ES LEY G pe Ge INDIVIDUAL GUEST INFORMATION GUEST NAMES ARRIVAL DATES DEPARTURE DATES Remy ILE > 201 OCT +* DOiS— CHARGES TO BE BILLED (please indicate by marking an X in the appropriate boxes below) JARLL CHARGES |] CATERING AND MEETING CHARGES [| GUEST ROOMS & TAXES {] GRP ROOM DEPOSITS: AMOUNT $ {] GUEST INCIDENTALS [] CATERING DEPOSITS: AMOUNT § { ] OTHER (Description): PLEASE NOTE THAT UPON RECEIPT OF THIS FORM THE CREDIT CARD WILL BE CHARGED FOR THE FULL AMOUNT OF ROOM AND TAX IF YOU OPT TO COVER ALL CHARGES, THE INCIDENTAL CHARGES WILL BE SETTLED UPON CHECKOUT OF THE GUEST. CARD HOLDER INFOR! CARD NUMBER: EXPIRATION DATE: 8/ /& NAMES APFEARS ON CARD JEFFERY €. EpsTewn —_ CARD BILLING aDprEss:_F_ ([ AST IST ST T STATE AND ZIP CODE: ( TELEPHON’ [] AMERICAN EXPRESS [} VISA[ |] MASTER CARD ({] DINERS CLUB [] DISCOVER (j)jcs 1 HEREBY AUTHORIZE THE MARK HOTEL TO USE THE CREDIT CARD INFORMATION PROVIDED ON THIS FORM EITHER AS PAYMENT FOR THE CHARGES DESCRIBED ABOVE I AM AWARE SUPPORTING DOCUMENTATION WILL ACCOMPANY ALL CHARGES. BY SIGNING BELOW | AGREE TO PAY MY CREDIT CARD ISSJER FO®-1HE CHARGES AGREED TO ABOVE IN ACCORDANCE WITH MY CARDHOLDER AGREEMENT. / { ‘ \ 7 CARD HOLDER'S SIGNATURE: {/ DATE SIGNED: TT x — RE K SEPT. LY SOi$ = 9 \ PLEASE ATTACH: 1) A LEGIBLE PHOTOCOPY OF PROOF OF IDENTIFICATION 2) FRONT AND BACK OF THE CREDIT CARD YOU WISH TO CHARGE 25 East 77S Street, New York, NY 10075, USA Tel: 212-744-4300 Fax: 212-606-3102 www, themarkhotel.com Toll free reservations: 1-866-744-4300 EFTA00311423

--=PAGE_BREAK=--

EFTA00311424