Credit Card Authorization

Please fill out the information below and sign and submit. After that, please send a photocopy of credit card (front & back), driver license and fax it back to above fax number or email it to nassauholidaymotel@comcast.net.

"*" indicates required fields

No spaces, no hyphens.
3 or 4 digit security code
Card Billing Address*
Use your mouse/trackpad cursor to sign above.