S A Credit Card Authorization Form THE PENINSULA 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. We ask that you either fax this completed form to The Peninsula Spa at or e-mail it to Third Party Payment of Services ONLY Guest Name: | _ Date of Services: _ Rate Information and Approved Charges Services: Rate: CJ Service ONLY CI Service and 4.5% Sales Tax ONLY LService, 4.5% Sales Tax and Gratuity % 1) Additional Services Rendered (i.e. Treatment Upgrades) | [) Products Purchased Maximum Allowable Amount: O27ed Please Keep My Form on File For Future Use JX) Cardholder Information Name as it appears on the credit card: : Type of Card: (1 Visa (1 Mastercard (7K american Express ([] Discover Account Type: Individual (Personal Credit Card) Credit Card Number: ___ Expiration Date: ; Address (Billing Address): _ City, State and Zip: v vr . 7 Phone Number: Fax or Alternate Number: I certify that all information is complete and accurate. I hereby authorize The Peninsula Spa, New York to collect payment for all charges as indicated on this form by processing a charge to the credit card listed above. I certify that I am the authorized signer of the credit card listed above. Please note that we require a hgydwritten signature in order to process this order. Cardholder Signature: ___ Date: [0/12/] Y EFTA00313333