PULLMAN RIGA OLD TOWN HOTEL 24 JEKABA STR. LV-1050 RIGA LATVIA +371 67815444 H9619@accor.com PULLMANHOTELS.COM ~ ACCORHOTELS.COM AUTHORISATION TO CHARGE MY CREDIT CARD ACCOUNT Room reservation conformation . | Name (as it appears on card): EFFREY.. EPSTE!,| Card type (please check): ee VISA [] Mastercard / Eurocard [] Maestro Expiry date: = UNE 20 | Y By signing this form, | authorize Hotel Pullman Riga Old Town to charge my credit card account with the following amount: (currency) US. DELLABS (amount) 6IZCO0.2° for (description of the services purchased; confirmation/invoice number): Room Ave TAKES FEES INCIDENTALS Date: Nov 2- Il, QSOut Place of signing: . U yy N Signature of cardholder: Completed authorization form should be #mailéd to: H9619@accor.com +371 67815444 7 Contact person handli okings: l-¥ 7-5 +7- OTF 7 Please keep a copy of this form for your own records! EFTA00313771