Authorization For Billing to 3^rd Party Credit Card

Please print and fill out the form below and fax a clear photocopy of the front and back of the credit card that is to be billed to 519-534-5180. 

Name of Guest:

Reservation Number:

Arrival Date: Number of Nights:

Name of Card Holder:

Mailing Address of Cardholder:

Telephone Number: Fax Number:

Credit Card Number: Expiration Date:

Charges To be Billed: (Please Select An Option Below)

I the undersigned, hereby Authorize to bill the above charges to my credit card which appears above.  I have attached a clear photocopy of the front and back of this card.  I accept that by guaranteeing the room, and that I am also taking responsibility for the room and will be held liable for any damages that may occur while occupied by my guest.

Signature of Cardholder: _________________________________________

Date: ________________________________________________________