ShannonCC

General Credit Card Submission Form

* Indicates required field

Name (as it appears on the card) *

Credit Card Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Lead Guest on the reservation (if different) *

Card Information

Card Type *

Account Number *

Expiration Date *

CVV Code *

Important Disclaimer:
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. This payment authorization is for the type of bill indicated above. 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; provided the transactions correspond to the terms indicated in this authorization form.

Initial for disclaimer *

Amount approved for this transaction: *

Would you like to keep this card on file for future payments? *

Yes No

Are you interested in travel insurance? *

Yes No

Please Electronically Sign Your Name *

Date of Signature *

Comments or Questions? *

Submit

General Credit Card Submission Form

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