Subject: RE: Salle complémentaire pour interview 20-10-2016
Date: Tue, 18 Oct 2016 13:24:43 +0000

Credit Card Authorization Form  I, …………………………………………………………………… herewith authorize “S.A.Hotel BLOOM! N.V.” to charge my credit card.   Name: .......................................................................... First name: ................................................................................. Address: ............................................................................................................................................................................ City: …………………………………………Country: ……………………………………………… Postcode: ………………………………………………….  Tel (        )..................................................................... Fax (        )...................................................................................... Email:…………………………………………………………………………………………….……………………….……………………………………………………  My credit card details: Credit card type: ………………………………………………………………………………………….………………… Credit card number: ………………………………………………………………………………………….………………… Exp. Date: ……………………… The hotel BLOOM! Brussels accepts following credit cards: American Express/Eurocard Mastercard/Diners Club/Visa.    What I wish to pay for: Client’s name: ………………………………………………………………………………………….…………………  Arrival date: ………………………………………………………  Departure date: …………………………………………… I wish to cover the following:   Room, city tax  Breakfast   Seminar packages, breakout rooms  Restaurant/Bar  Parking  Telephone  Other: ………………………………………………………………….… Maximum amount authorized: …………………..€ (no amount mentioned = no limitation; in the case that the invoice’s amount is above the amount authorized, it will be asked to the guest to pay the difference upon departure).  I enclose a copy of the front and back of my credit card and ID with this authorization form.  Yours sincerely,  Date:          Signature: Rue Royale 250 - 1210 BRUSSELS - BELGIUM Tel: +32 2 220 69 06  Fax: +32 2 217 84 44 E-mail: [email-masked]  Website: www.hotelbloom.com