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� DECATUR �(�NFEF;ENCE <br /> CENTER �l�1�TD HOTEL <br /> 4191 US Highway 36 West I <br /> Decatur, IL 62522 <br /> 217/422-8800 217/422-9155 (Fax} <br /> CONFERENCE HOTEL <br /> CREDIT CARD PAYMENT FORM <br /> Accept this as authorization for the Decatur Conference Center and Hotel,Decatur,Illinois,to bill the following <br /> credit card for charges incurred: <br /> Bill All Charges(guest room, tax, incidentals, meeting room rental&catering charges) <br /> Bill guest room, tax, &incidentals only <br /> Bill guest room &tax <br /> Bill meeting room rental cP�or catering charges only <br /> Bill deposit only in the amount of$ <br /> Dates(s)ofFunction 09/17/2009 <br /> Credit Card Number Expiration Date <br /> Organization Names Regional Neigborhood Network Conference <br /> Cardholder Name <br /> IN THE EVENT YOUR COUNT EXCEEDS THE PREPAID GUARANTEE NUMBER, WE <br /> REQUEST THIS CREDIT CARD AUTHORIZATION FORM ON FILE FOR ANY ADDITIONAL <br /> CHARGES OVER YOUR PAID GUARANTEE THAT YOU AUTHORIZE. THIS FORM IS FOR <br /> YOUR CONVIENIENCE SO WE WILL NOT NEED TO INCONVENIENCE YOU DURING YOUR <br /> EVENT. <br /> Cardholder Signature <br /> Address <br /> City ,State Zip Code <br /> Phone Fcrz <br /> 7 <br />