Sign and complete this form to authorize Villa Antiche Mura to make a one time debit to
your credit card listed below.
By signing this form you give us permission to debit your credit card for the amount
indicated in this form. This is permission for a single transaction only, and does not provide
authorization for any additional unrelated debits or credits to your account.
Please complete the information below, all fields marked by an asterisk (*) are mandatory: