Hotel London, Odessa Ukraine · About the Hotel

Cardholder authorization form

1. Arrival date*:

2. Departure date*:

3. Rate*:

4. Room*:

5. In lieu of my credit card imprint I (name of cardholder shown on credit card)*:

6. First Name*:

7. Last Name*:

8. Nationality*:

9. Passport #, date and place of issue*:

10. Country*:

11. City*:

12. ZIP:

13. Phone*:

14. Fax:

15. E-mail*:

16. Card Number*:

17. Valid till (MM/YY)*:
/

18. 4 printed digits above or below card number*:

19. Amount*:

20. This charge is related to hotel services for myself (full name of cardholder):
Guest 1
Guest 2