ROCCO FORTE HOTELS SF CREDIT CARD AUTHORISATION FORM Cornamennue 06 omiate i Please complete and fax the form to Noxasyicra, 3anoiHMTe AaHHy1o bopmy u oTNpaBsTe eé no baxcy Or alternatively email to the following dedicated email address : Hau oTnpabbte Ha 3A€KTDOHHYW NoyTy: | will be ible for charges to the value of / A paspewaio CHaTe C Moe KapTe Cymmy 8 pasmepe : 3X bo CRUsB 3a mM, OK BEM vie: Single event /EanHospemeHHo CI Monthly /ExemecauHo C] Annually /Emerogno El Other/Rpyroe CO Please specify/Nomanyitcta, noracuuTe 1 wish the charges incurred on the above account(s) to be settled in the following manner: Al paspemiaw NponsBecTH CHATHE ACHEAHBIX CpeACTB CAC AyIOULIM O6pasom: Credit Card Type: Credit Card Number: Homeo (pes OW KapTer: Kapra gekctentenbHa 0: Issue Number (for Maestro only): Homep sbinycka: (ToAeKo ANA KapT Maestro) Start date (for Maestro only): Kapte qevcrentenbna c: (ronbKo Ana KapT Maestro) vc Tenn Card Holder Signature: Noannce gepmatena Kaptol: ashe Name (in capitals): U0 (nevatHbwan Gyxsamu): He béleleINOEESHeNwWOOOO0O Statement Address for Credit G EAST FIST STreer pth hte NEw yor, 0022 Contact Telephone Number / a a Proof of card holder’s identification may be required with this form (Passport) / K aaHHoii OopMe MoxeT NOTpe6oBaThCA NPHAOAHTL KONMW AOKYMeHTa, YAOcToBepswoulero AM4HOCTS AepxaTena (nacnopT) Full Card Number / Homep kapTer: Credit Card Type / Tun xaprei: Credit Card Expiry Date / Kapta aeAcreutenbHa Ao: EFTA00314069