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 email it to nassauholidaymotel@comcast.net.

"*" indicates required fields

Cardholder Name*

Credit Card Type*

Credit Card Number*

No spaces, no hyphens.

Expiration Month*

Expiration Year*

Security Code*

3 or 4 digit security code

Card Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Card Holder Signature*

Use your mouse/trackpad cursor to sign above.