Credit Card Authorization Form | Brickell





*Title (* = required) Mr.Mrs.MissMs.
*First name *Last name
*Company name Job title
*Address Address 2
*City *State
*Country *Zip Code
*Telephone *Email
– Billing address if different from above
Billing address Billing address 2
City of Billing address State of Billing address
Zip Code of Billing address Country of Billing address
* Required fields
Brickell Meeting room Package Order/Charge
Back to see package details

Please make a selection.
Brickell Location
Meeting room 8 people $47.00 per hour
Board room 14 people $59.00 per hour
Start Date MM/DD/YYYY *Hours *End Date
*Terms and Conditions
I have read and agreed to the Terms and Conditions and by completing this transaction intend this to be an agreement signed by me.

*Initials Signature

Credit Card Details VISA - MASTER CARD
*Name on Card: *Card type:
*Credit Card Number:
*Expiration date: Month *Year:
*Card Verification # / Security Code: Issue Number (optional)