Island Services

My Padre Rentals and Property Management

Authorization Form
(Please print or type this form)
Form should be sent by U.S. Mail
Credit Card Charge

U.S. Mail: Island Services
           P O Box 2392

           South Padre Island
           Texas        78597                               

Email:     mypadre1@aol.com                              

1.) Reservation #_______________________

2.) Last Name: _________________  First Name: _________________ Init: ______

    Address: _______________________________________________________________

    City: ________________________ State: ___________ Zip: _________________

    Phone: (____)_________________

3.) Fill in all blanks.  Attach legible photo copy of front and back side of credit

    card, and front side of card holder’s drivers license.

      Type of Card:_______________________
 

      Credit Card #: _______________________________ Expiration Date: _____________

      Drivers License#: ____________________________  State: ______________________

      Name of Card Holder: ________________________________________________________

      Credit Card Billing Address: ________________________________________________

      City: ___________________________________  State: _______  Zip: _____________

      Day Time Phone #: (____)________________________

      Evening  Phone #: (____)________________________

      Mobil Phone #:    (____)________________________

      Authorized amount of charge:  $_________________

      Card Holder Agreement

I authorize Island Services to charge my credit card for the stated amount.  I understand that once charged all funds are non-refundable for any reason, including but not limited to death or illness.  I wave all rights to charge back authorized amount of funds.

Card Holder Signature: __________________________Date: _____________________

 
Phone: 956-761-2649 * Fax: 956-761-4251

 http://www.mypadre.com     email: mypadre1@aol.com