credit card authorization Location:* State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Washington Wisconsin Metro Area Hotel Cardholder Info: Cardholder Name* Company Name Billing Address* City* Country* Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic Of Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Rep. Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, S. Sandwich Islands Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia (Serbia/Montenegro) Zambia Zimbabwe State / Province* State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PQ RI SC SD TN TX UT VT VA WA DC WV WI WY Postcode / Zip* Telephone* Email Address* Request Receipt * Confirm Email Address * Checking this box will cause an email to be sent to the cardholder with an attached folio each time the card is charged. The folio will show all charges for that guest from check-in through midnight on that day. Guest Info:* Credit Card Info: Guest First Name Guest Last Name Payment Date From Payment Date To Add Additional Guest Name on Card* Card Number* CVV Security Code* Where to find Expiration Date* MO 01 02 03 04 05 06 07 08 09 10 11 12 YR 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 I authorize ESA Management, LLC to charge all room and tax charges to the named guest(s) at the hotel indicated on this form for the payment dates listed to my credit card; and in addition, all charges checked below: Telephone Charges Incidental Charges Bill my credit card* For Entire Individual Stay at check-in Every 7 nights for each guest (credit card will be charged 7 nights at check-in and then every 7 days) Every 30 nights for each guest (credit card will be charged 30 nights at check-in and then every 30 days) Comments(Optional): I authorize the above named hotel to charge the credit card indicated in this authorization form according to the terms outlined on this authorization form. This payment authorization is for the services described above. The cardholder agrees to pay for any extraordinary costs for repair, replacement or cleaning of the Guest’s room. 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 so long as the transaction corresponds to this authorization form. This is not a guarantee of a reservation, reservations must be booked separately. To complete the authorization to charge your credit card, you must type your name in the blank area below. This will serve as your electronic signature and is the legal equivalent of signing your name on a printed credit card authorization form. By checking this box and typing my name as printed on my credit card below, I am electronically signing this authorization form.* Authorized By: