Sign and complete this form to authorize Inn Beachway Inn to make a one-time charge to your credit card listed below.

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

The purpose of the charges is for the hotel stay for guest :

Guest Full Name :Check in Date :

Check in Date :

Billing Information

Billing Address : Phone :

City : State :

Zip Code : Email :

Card Details

VisaMasterCardDiscoverAmerican Express

Cardholder Name :Account/CC Number :

Expiration Date :

I authorize Inn Beachway Inn to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one (1) time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company

Signature
[signature* signature-172 color:#000000 backcolor:#dddddd width:300 height:130]
Date :