Debit/Credit Card Authorization Form

Debit/Credit Card Transaction Requirements

First name

Last name

Phone

Name on Card:

Billing Address

Zip code

Type of Card

Visa

MasterCard

Discover

Card Number

CVC

Expiration Month

Expiration Years

Arrival Date

Departure Date

Number of Days

Number of Rooms

Agreed total amount

I authorize Chief Motel to charge my credit or debit card for the agreed total amount for my stay, including all applicable taxes and fees.

Copy of the Credit/Debit card Front

Copy of the Credit/Debit card Back

Valid Government-Issued Photo ID

Signature

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