CREDIT CARD AUTHORIZATION FORM

NAME OF FUNCTION or
ORGANIZATION:
(or) NAME OF INDIVIDUAL:

ARRIVAL DATE: DEPARTURE DATE:

AUTHORIZED CHARGES TO BE BILLED TO CREDIT CARD

ALL CHARGES ROOM & TAXES ALL INCIDENTALS VALET PARKING

MEETING / EVENT CHARGES MOVIES FOOD & BEVERAGE
OTHER INTERNET DRYCLEANING
TELEPHONES LAUNDRY

INFORMATION AS IT APPEARS ON AND REGISTERED TO THE CREDIT CARD COMPANY NAME

COMPANY

FIRST NAME MIDDLE LAST

ADDRESS 1 ADDRESS 2

CITY STATE ZIP

COUNTRY PHONE CARD TYPE

CREDIT CARD # XXXXXX MONTH YEAR

FIRST 6 DIGITS LAST 4 DIGITS **Representative will call to confirm the remaining digits on card**

The undersigned hereby authorizes the to charge the above credit card for charges indicated above, and as indicated on any executed contract,
event orders, for the above referenced name/group/function. I understand that I am responsible for safe delivery of this form to the hotel.

NAME OF PERSON COMPLETING THIS FORM POSITION / RELATIONSHIP

Cardholder Signature Required DATE

HOTEL NAME La Quinta Inn Dallas

ADDRESS 4440 N Central Expressway Dallas, TX

ZIP 75206 Phone: (214) 821-4220 Fax: (214) 821-7685