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HOLIDAY INN NORWICH , CT
10 LAURA BOULEVARD
NORWICH CT 06360
FAX: 1-860-8891767, PHONE: 1-860-8895201

Payment Card Authorization Form

Please complete this form in its entirety, include all requested documentation,
and fax it to the hotel at least 3 days prior to check-in to allow for
processing. If you have fewer than 3 days before the check-in date, please call
the hotel for instructions. This Payment Card Authorization Form is valid for
the individual reservation(s) listed below.

Today's Date: _________________

I, _______________________ authorize use of my payment card for FULL PAYMENT of
the following:

Room & Tax Incidentals Banquet Charges Other __________________________________

This reservation will be guaranteed to the payment card provided. In the event
of a no-show, the payment card will be charged Room & Tax.

Guest Name Company Address Telephone/Fax (                 ) (                 )
Confirmation Numbers 1. 2. 3. 4. Arrival Date Number of Nights


Payment Card Number Expiration Date Name on Card Billing Address Telephone/Fax
(                 ) (                 ) Cardholder Signature


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