GRAND PALACE HOTEL | RIGA - LATVIA Pils strect 12 * Riga * LV 1050 + Lateia www.grandpalacerigs.com CREDIT CARD AUTHORISATION FORM Reservation for: Reservation from: Reservation until: Reservation Nr. I authorize “Hom! Grand Palace” L > amount of ¥00. 60; R fe Type of Credit Card Credit Card Number: Cryptogram number (CVC): Expiry date: Holder's Name: “Request cannot be processed wt IAQUAFQ4+ Pils street 12, Riga, Latvia, VAT teg. ne. L.V40003378078 mm the below mentioned credit card for all requested services > Holder's signature: te ites MARCH Company stamp: (of applicable ) kd THE LEADING HOTELS OF THE WoRLo {}= Ol}; INuca >| wtf ot re 2\ Ee. Cesteis) adhe SS es a egble front and tpeck mde copy of Mec codteant EFTA00313856