Payment Authorization Request:

Please complete this payment authorization form to allow the third-party expenses outlined below to be charged to your credit/debit card.
Click here to open Marriott Privacy Center
Guest Information

Confirmation Number: 76136007 Arrival Date: 5/30/2021 Departure Date: 6/5/2021

Guest Name: John Berg, Ronald Stringer, Alina Sixtos

Company Name:

Phone Number: (214)814-2816

Address: 2931 Shelby Avenue

City, State, Zip: Dallas, TX 75219-5735

Relation to Cardholder: ✔ Relative ✔ Friend Business Associate Other:

(if applicable)

Rate Information and Approved Charges:

■ All Charges Room & Tax Telephone (LD) Telephone (Local) Restaurant
Room Service Valet/Laundry Parking HS Internet Access Movies
Event/Catering/Banquet Charges
Other:

Currency type: American Express

Charges must not exceed for the entire stay/event

Room Rate: Taxes: Total Daily Rate: Number of Nights:

Comments/Special Requests:

Payment Information:

**** **** **** 5008

JOHNATHAN BERG
2931 Shelby Avenue
Dallas, TX 752195735
United States of America

APPROVED 5/31/2021 ID: 20210531023027293 Cardholder Phone Number: (214)814-2816

Acceptance and eSignature:

✔ I authorize the hotel mentioned above to charge payment for all charges as indicated in the Rate Information and Approved
Charges section of this form by processing a charge to the credit/debit card listed above. I confirm that all guests listed above are age 18
or older. I am the authorized signer for the payment information attached.

Cardholder Signature:
Johnathan Ryan Berg Date: 05/31/2021
machomanjoshpitt@gmail.com

Doc ID: 20210529194233461

Sertifi Electronic Signature