Airline Crew Lodging Solutions - Travelliance

10225 Yellow Circle Dr.Minnetonka, MN 55343U.S.A.Phone: (952) 767 8005I, (cardholder’s name as it appears on the credit card) ____________________________authorize Travelliance to charge my: American Express Visa MasterCard DiscoverCredit Card #_______________________________________________________Expiration Date:________/________/________ Security Code________Billing Address:Street Number & Name:____________________________________________________City, State & Zip Code:____________________________________________________PLEASE BE ADVISED THAT AS OF 2/16/2015 THE MERCHANT WILL NO LONGER APPEAR AS NATIONWIDE HOSPITALITY AND WILL SHOW UP AS TRAVELLIANCE MINNETONKA US. IF THERE IS A RESTRICTION ON YOUR ACCOUNT PLEASE CONTACT THEM IN ADVANCE OF PROCESSING YOUR PAYMENT. THANK YOUThe following amounts and invoices numbers to be charged to the credit card listed above:________________________________________________________________________________________________________________________________________________Note: The person executing this agreement, and, if applicable, the entity on whose behalf such person is executing this agreement shall be jointly and severally liable for the payments of all charges incurred pursuant to this agreement.Print Name:______________________________________________________________Signature:_______________________________________________________________Date:___________________________________________________________________**Please fax this form to (952)-225-1065 Attention William Graham**or email AR@ ................
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