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This is to verify that I, _____________________________________________,
hereby authorize Pavel Alter, Inc.
to debit my Visa / Master Card / American Express / Dinners Club
card number _____________________________________________________
expiring on ___________________ for the amount of $ ________________
card billing address _______________________________________________
__________________________________________________________________
as payment of rent and/or security deposit for my accommodation
at ____________________________________________. I represent that the
premises will be occupied only by myself and my _______________ guest(s)
arriving on __________________ and departing on ___________________ . |
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I agree that my credit card may also be used as a guarantee against any additional charges that I, or my guests, may incur as a result of our occupancy of the above captioned premises including, but not limited to, an extension of our stay beyond the above mentioned date of departure, occupancy of additional guests not listed on my reservation form, missing or damaged property (beyond normal wear and tear), long distance telephone bills and pay per view television programs. |
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Pavel Alter Inc.
115 W 25th Street, New York, New York 10001 (between 6 and 7 Avenue)
telephone: 212-741-4555, fax: 646-230-7042,
cell: 917-453-3109 |
