Instructions

1. Print this page

2. The Credit Card Owner must HAND-SIGN this form

3. Fill it and send back by FAX or E-mail in attachment

4. FAX (+55-22) 2623-6317  / E-Mail: Pousada@sanfrancisco.com.br

• Credit Card Holder Name: _________________________________________

• Credit Card Number: _____________________________________________

• Exp. Date: ____/____ /____

• Secure Code No.: __________________

• E-mail : ___________________________________________________________

• Adress : ___________________________________________________________

• State:___________________________________

• Country: ________________________________

• Phone: (     )______________________________

• Name of the Guest in the Reservation: __________________________________

• Arrive:           ____/____ /____               Departure:   ____/____ /____

•  

I hereby authorize Pousada Buzios San Francisco to verify the above information as well as to charge the agreed fare. I consent that I understand the rules and regulations of the Cancelation Policy on including all fees and penalties that may apply.

• Amount to Debt on my Credit Card: R$ ______________________________

___________________________________________________________________________

  Hand Signature of the Credit Card Owner