Hotel Credit Card Payment Form
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1Hotel Credit Card Payment Form
C&H International,
4751
Wilshire Blvd.,
Ste 201,
Los Angeles
Tel: 800 - 833 - 8888
Fax: 323 - 939 - 2286
Fax this completed form to 323-939-2286
Booking Number: _________________________
Provider Conference: ________________________
Hotel Name: _____________________________________________________________________________
Check in: _________________________
Check out: ________________________
Credit Card:
American Express
MasterCard
VISA
Discover
Credit Card Number: _____________________________________________________________________________
Cardholder's Name: _____________________________________________________________________________
( exactly
as
imprinted
on
credit
card )
American Express
MasterCard & VISA
Exp. Date(MM/YY): _________________________
CVV2: _________________________
Total Amount Charged: $ _________________________
Cardholder's Billing Address: _____________________________________________________________________________
City: _________________________
State: ________________
ZIP:_____________________
Phone Number: _________________________
E-Mail Address:____________________________________
Identification is required. Please provide copy of the credit card (front and back) and driver's license of cardholder.
By signing below, I authorize C&H International to charge my credit card for the amount described above. Payment in
full to be made when billed or in extended payments in accordance with standard policy of credit card issuing
company. I future acknowledge that I have been informed of the cancellation and refunds policies and agree to the
terms and conditions.
Cardholder's Signature _________________________
Date _____________________
To be completed by Travel Agent ( If unable to obtain above Cardholder's signature and/or supporting documents)
I have verified the above cardholder's identification and agree to assume all responsibility for any charge-backs or
credit disputes pertaining to the above booking.
Agent Name: _____________________________________________________________________________
Representative Name: _____________________________________________________________________________
Address: _____________________________________________________________________________
City: _________________________
State: __________________
ZIP:_____________________
Phone: _________________________
Fax:_____________________
E-Mail Address: _____________________________________________________________________________
Signature of Representative _________________________
Date _____________________
CST # 1016644-40
The Leading Travel Consolidator
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Parent category: Financial