USA Hospitality, Inc.
11505 Satellite Blvd. Orlando, FL. 32837
 Phone 407-903-1600
 Fax 407-386-9798
    

	

    

        
Credit Card Authorization Form

        

            

                
                                

                    Name *
                                            
                                    
                                
                                

                    Invoice
                                            
                                    
                                
                                

                    Amount *
                                            
                                    
                                
                                

                    Billing Address *
                                            
                                    
                                
                                

                    Zip Code *
                                            
                                    
                                
                                

                    CID# (Number on back of the card) *
                                            
                                    
                                
                                

                    PAYMENT *
                                             Visa  Master Card  American Express  Discover  Diners
                                    
                                
                                

                    Card Number *
                                            
                                    
                                
                                

                    Expire *
                                            
                                    
                                
                                

                    Copy of credit card and official identification (driver's license) must be attached to form (PDF or jpeg.)
                                            
                                    
                                
                                

                    Driver's License
                                            
                                    
                                
                                

                    AGREEMENT *
                                             Customer will authorize USA Hospitality to keep the credit card on file to pre-pay for open invoices prior to delivery day. 
                                    
                                
                                

                    Card Holder Name *
                                            
                                    
                                
                                

                    Date *
                                            
                                    
                                
                                

                    Electronic Signature *
                                            
                                    
                                            
            

                
                SUBMIT
    		
    	
    


            

For the purpose of payment for approved charge incurred during our business relationship.
This authorization will remain in effect during the business relation or until the expiration of said card. At which time USA Hospitality will require the completion of another Authorization form.
**Credit Card and Identification must be presented upon initiating service.

USA Hospitality, Inc.
11505 Satellite Blvd. Orlando, FL. 32837
Phone 407-903-1600
Fax 407-386-9798
Email: admin@usahospitality.com
www.usahospitality.com