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.• <br /> DECATUR CONFERENCE CENTER AND HOTEL <br /> DECATUR,IL <br /> DIRECT BILL APPLICATION <br /> Company/Organizarion Name Regional Neigborhood Network Conference <br /> Phone Number 217-424-2864 <br /> Fax Number - - <br /> Date(s)of Event 09/17/2009 <br /> CHECK ONE OR BOTH <br /> ❑ I am requesting direct billing for one ❑ I would like a direct bill account <br /> Specific function on established for future use. <br /> DIRECT BILL THE COMPANY NAMED ABOVE FOR THE FOLLOWING(PLEASE CHECK ALL THAT APPLY) <br /> Sleeping Room&Tax Incidentals Other(Please be specific) <br /> Meeting Room Only All Charges <br /> REFERENCES: Two hotel or Convention Centers where you have recently direct billed(Within past 2 years) <br /> Name of <br /> 1 HoteUConvention Center <br /> Address <br /> Phone <br /> Name of <br /> 2 HoteUConvention Center <br /> Address <br /> Phone <br /> Please write below the exact address to which you want your invoices and statements billed: <br /> COMPANY or ORGANIZATION NAME <br /> CONTACT NAME <br /> ADDRESS <br /> CITY, STATE AND ZIP <br /> CONTACT PHONE NUMBER <br /> The information above is correct. I understand that payment should be made in full within thirty days from the date of <br /> the first billing or the account will be subject to a 1 1/2 %service charge per month.(Annual rate of 18%) <br /> Authorized Signature Date <br /> Please fax or mail complete application to: <br /> Print Name Decatur Conference Center and Hotel <br /> Attn: Accounts Receivable <br /> 4191 West US Highway 36 <br /> Decatur, IL 62522 <br /> 217/422-9155 (FAX) <br /> Approved By: Decatur Conference Center and Hotel Controller <br />