THE BREAKERS PALM if ACH CREDIT CARD AND CITY LEDGER AUTHORIZATION FORM I Tr Ft= (2-g-`1 PP S11 I td hereby authorize The Breakers Palm Beach, Inc. to collect payment for the following charges (only items that are checked), by processing a charge to the credit card or city ledger account listed below. Room and Tax Parking Incurred by: From (date): Food and Beverage Bungalow All Charges Reservation Confirmation Number: until (date): H0 of . Card Type: Visa Amex MC Diners Discover: JCB: Account Type: /Individual (personal credit card) Corporate (Company Name) Credit Card #: Expiration Date: CIV (Security Code): City Ledger # (Club Members): (3-4 digits found on the face or at the bock of the credit card) Driver's License #: (Required if paying by credit card) Cardholder's Name: Cardholder's Address: Cardholder's Phone Number: Cardholder's Email Signature: On cocas - 12.7-,71- PEREN Ps—rOst.1 9 tiips—r 44-( ST.. m\1 10021 Date: SPapep. --Please note that this authorization is valid for any type of "Debit" card--- Please return form via email t sender or fax to 561-659-8403 **Please include a photocopy of the front and back of Credit/Membership Card" EFTA00313780

AMERICAN EXPRESS EFTA00313781

EFTA00313782