Hilton Springfield Credit Card Payment Authorization Form Please complete all areas below. Incomplete requests may be rejected. This form must be received at least 5 business days prior to the Check-In, or by specified date in Event Contract, to ensure acceptance of the credit card to be charged. Do not send completed form by email. FAX COMPLETED FORM TO: 217-789-0709 ATTN:Front Desk____________________ HOTEL USE ONLY: Date: _____________________________ Authorized Amount: Approval Code: Date: CARDHOLDER - Please complete the following section and sign/date below: Guest / Group Name:____________________________________________________ Check-In / Event Date:_________ Name of Person/Group Making Reservation:_________________________ Phone:_______________ Cardholder Name as it Appears on Credit Card:________________________ Cardholder Billing Address:___________________________________________________

City:___________________ State:________ Zip:_________ Daytime /Business Telephone:__________________ Evening Telephone:____________________ Credit Card Number:_____________________________ Expiration Date:__________ Credit Card Type: (Check one) Visa/MasterCard_____ American Express_____ Discover_____ JCB_____ Diners Club_____ Credit Card Issuing Bank Name:______________________ Bank Phone Number (from back of your credit card):________________________ I agree to cover the following categories of charges: (Please check) All Charges_____ Room & Tax______ Food & Beverage_____ Retail_____ Incidentals (Movies, Phone Charges, etc)_____ I agree to cover the above categories of charges up to a Maximum Amount of $ __________________ DIRECT BILL ACCOUNT PAYMENTS ONLY: (For direct billing customers paying by credit card) Name on Invoice/Statement _______ ______ Date on Invoice/Statement ______________ Invoice/Statement Number ________________________________________ Authorized Amount $_______________________ Note: Charges for room and tax, group deposits or direct bill account payments will be charged to your credit card immediately. Any incidental charges circled above will be charged at the time of check-out. Amount to be immediately charged to credit card for room and taxes or deposit: $______________ Final Balance Billed to Credit Card (hotel use only): $_______________ By signing below, you authorize the hotel to charge your credit card immediately for the amount indicated above up to the “Maximum Amount” indicated above. You further acknowledge that if “all charges” has been selected, then all guest/group related charges (less Deposit) will be charged to the above card number at the time of check-out or event conclusion. Cardholder Signature:____________________________ Date:_________________________