Fax This Form to 319-373-4111 Or Email To

SHIPPING FORM – MICROTEL INN & SUITES MARION

SHIPPING INFORMATION Name: Date:

Shipping Address: City:

State: Zip:

Telephone: Email:

RESERVATION INFORMATION Name on Reservation: Arrival Date: Departure Date:

PAYMENT INFORMATION Card Type: Name on Card:

Card #

Expiration: Card Security Code (3 digit number on back):

TERMS  All Items are shipped without insurance and without liability to Microtel Inn & Suites  All items are shipped via UPS unless otherwise agreed upon  Payment includes shipping cost, shipping supplies, pickup, and handling fee  Any Item valued over $100 will require a signature and may be subject to additional fee  If shipping will cost more than $25, we will contact you first for additional authorization PAYMENT AUTHORIZATION By Signing Below, you authorize Microtel Inn & Suites Marion/Cedar Rapids to charge up to $25 to my payment method above for shipping costs. You also understand that any attempted chargebacks for non-fraudulent transactions will be subject to criminal investigation and will be prosecuted to the fullest extent of the law.

Signature______

ADDITIONAL PAYMENT AUTHORIZATION (complete this section only if we contact you for shipping costs over $25)

I Authorize Microtel Inn & Suites to charge: ______to my payment method above. By signing below, you authorize Microtel Inn & Suites Marion/Cedar Rapids to charge your payment method for the amount listed above. You also understand that any attempted chargebacks for non-fraudulent transactions will be subject to criminal investigation and will be prosecuted to the fullest extent of the law.

Signature______Fax this form to 319-373-4111 or email to [email protected]