CREDIT CARD AUTHORIZATION FORM

FOR PAYMENT

The following charge of $_____________ will be added to your credit card for the following services provided by

The Conference Center at The Rensselaerville Institute:

Services Provided:____________________________________________________________________________________________________________________________________________________

We need the following information from you to do your credit card transaction:

Credit Card Holder (full name):__________________________

Credit Card Number:__________________________________

V-code (last 3 numbers from back of card in signature space): ______________________

Expiration Date:_________________

Type of Credit Card:___________________

Authorizing Signature:_________________________________

Please fax this form back to us at:

The Conference Center

at The Rensselaerville Institute

63 Huyck Road, P. O. Box 128

Rensselaerville, NY 12147

FAX: (518)797-3692

PHONE: (518)797-5100