Parkway Inn
766 Cosby HWY
Newport, TN 37821
(423) 623-6006


THIS FORM IS TO BE COMPLETED BY THE HOTEL AND THE CARDMEMBER TO 
AUTHORIZE THAT HOTEL CHARGES FOR GUESTS OTHER THAN THE CARDMEMBER MAY 
BE CHARGED TO THE CARDMEMBER'S ACCOUNT

 

NAME & ADDRESS OF HOTEL: 
___________________________________________________________

DATE THIS FORM IS COMPLETED: 
___________________________________________________________

RESERVATION NUMBER(S): 
___________________________________________________________

CARDMEMBER NAME: 
___________________________________________________________

CARDMEMBER ACCOUNT 
NUMBER:__________________________________________________________

CARDMEMBER ADDRESS: 
___________________________________________________________

EXPIRATION DATE: 
___________________________________________________________

CARDMEMBER PHONE NUMBER: 
___________________________________________________________

CARDMEMBER FAX NUMBER: 
___________________________________________________________

 

ROOM REQUIREMENTS:  Number of Nights Arrival Date Departure Date Room 
Rate

 _______________ __________ _____________ ___________

FOR ABOVE CARDMEMBER

FOR GUEST(S)/EMPLOYEES (IF DIFFERENT FROM CARDMEMBER):

NAME: ________________________________ _______________ __________ 
_____________ ___________

NAME: ________________________________ _______________ __________ 
_____________ ___________

NAME: ________________________________ _______________ __________ 
_____________ ___________

NAME: ________________________________ _______________ __________ 
_____________ ___________

NAME: ________________________________ _______________ __________ 
_____________ ___________

NAME: ________________________________ _______________ __________ 
_____________ ___________

 

THE FOLLOWING GUEST CHARGES MAY BE BILLED TO THE CARDMEMBER ACCOUNT:

o   Room and tax only

o   Room, tax, meals and incidentals

o   Advance Deposits (if required)

 

MERCHANT DEPOSIT POLICY

ADVANCE DEPOSIT REQUIRED?      Yes _____ No ______

IF YES, DEPOSIT REQUIRED PER ROOM IS:     $______________

TOTAL DEPOSIT REQUIRED IF MORE THAN ONE ROOM:   $______________

 

CHECK THE APPLICABLE DEPOSIT REFUND POLICY:

_____DEPOSIT PER ROOM IS NON-REFUNDABLE

_____DEPOSIT PER ROOM IS REFUNDABLE IF CANCELLATION IS MADE BY ___PM, 
(INSERT #)____________DAYS PRIOR TO ARRIVAL

 

A   RESERVATION FOR A STAY BY THE CARDMEMBER OR BY ANY GUESTS/EMPLOYEES 
OF THE CARDMEMBER LISTED ON PAGE ONE MUST BE CANCELLED BY (fill in) 
_______ PM on the (circle one) DAY OF/ DAY BEFORE THE SCHEDULED ARRIVAL 
DATE OR THE CARDMEMBER WILL BE CHARGED FOR THE FIRST NIGHT OF EACH STAY 
NOT CANCELLED.

 

 

TO BE COMPLETED BY CARDMEMBER:

By signing this form below,I agree to be responsible for any charges 
billed to my account based on the terms and conditions shown on this 
form, and for the types of charges I have agreed may be charged to my 
account for the list of guests/employees I have provided above.

 

I understand that if any advance deposit has been required by the 
hotel, the amount of the deposit will be billed to my above-listed Card 
Account Number immediately upon receipt of this signed form. For any 
exception to the merchant cancellation policy indicated on this form, I 
must obtain written concurrence from the above listed merchant, which 
must be provided to American Express as support in the event of a 
billing dispute, and retain such record for one year after the room 
charge. I understand that if any room reserved is not used and was not 
cancelled in accordance with the above cancellation policies, then my 
Card Account will be billed the amount described in the cancellation 
policy.

 

CARDMEMBER SIGNATURE AS APPEARS ON CARD:

_______________________________________________________

 

PRINT 
NAME:                                                                   
                                 DATE SIGNED:

_______________________________________________________  
______________________________