83 THE BREAKERS PALM BEACH CREDIT CARD AND CITY LEDGER AUTHORIZATION FORM rc lL. | Cc FEZEN EPs Le inl 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): __/ f. 333014 Reservation Confirmation Number: BoAS Af if Yo! ( Card Type: Visa _ Amex VA Discover: pe ae Diners Soe ane JCB: Account Type: JS Individual (personal credit card) ___ Corporate (Company Name) Credit Card #: Expiration Date: CIV (Security Code): City Ledger # (Club Members): (3-4 digits found on the face or at the back of the credit card) ——— ae Driver’s License #: PREecoas 24 (Required if paying by credit card) Cardholder’s Name: mr EPFREY Ese) T UY 1005! Cardholder’s Address: Cardholder’s Phone Number: Cardholder’s Email Signature: : , 2 A —_ Date: Nov. '#50D ~~Please note that this authorization is n valid 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** EFTA00313786