5) THE BREAKERS PALM @EACH CREDIT CARD AND CITY LEDGER AUTHORIZATION FORM hina c FEREN [ps Le wl hereby authorize The Breakers Palm Beach, Inc. to collect payment for the following charges (only items that are checked), by processing a charge to the credit card or city ledger account listed below. Room and Tax Food and Beverage ___ Bungalow ___ Parking All Charges Incurred by: From (date): until (date):_ Jo Y . 99 a01F Reservation Confirmation Number: Pd Card Type: aaa Amex 4 Discover: MC Diners eal JCB: Account Type: _/ Individual (personal credit card) ___ Corporate (Company Name) Credit Card #; Expiration Date: CIV (Security Code): (3-4 digits found on the face or at the back of the credit card) City Ledger # (Club Members): = - Driver's License #: _BROOCdaSs e274 (Required if paying by credit card) Cardholder's Name: ser ELEY Este) Cardholder's Address: a Easy Hs UY 100>| Cardholder’s Phone Number: Cardholder’s Email Signature: ) bh. < Date: Nov. '4505 =a a ~~Please note that this authorization is npevali for any type of “Debit” card~~ Please return form via email to’sender or fax to 561 -659-8403 **Please include a photocopy of the front and back of Credit/Membership Card** EFTA00313780

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- EXPRESS oes 21 eae E EPSTEIN EFTA00313781

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EFTA00313782