KIMPTON HOTEL FONTENOT , LA
501 TCHOUPITOULAS ST.
NEW ORLEANS LA 70130
FAX: 1-504-3243001, PHONE: 1-504-5711818
Payment Card Authorization Form

Please complete this form in its entirety, include all requested documentation, and fax it to the hotel at least 3 days prior to check-in to allow for processing. If you have fewer than 3 days before the check-in date, please call the hotel for instructions. This Payment Card Authorization Form is valid for the individual reservation(s) listed below.

Today's Date: _________________

I, _______________________ authorize use of my payment card for FULL PAYMENT of the following:

Room & Tax Incidentals
Banquet Charges Other __________________________________

This reservation will be guaranteed to the payment card provided. In the event of a no-show, the payment card will be charged Room & Tax.

Guest Name
Company
Address
Telephone/Fax (                 ) (                 )
Confirmation Numbers 1. 2.
3. 4.
Arrival Date
Number of Nights

Payment Card Number
Expiration Date
Name on Card
Billing Address
Telephone/Fax (                 ) (                 )
Cardholder Signature