Please, fill out this form and send it by fax to :(55) (21) 2275-9011

From:  COPINHA HOSTEL LTDA.

CREDIT CARD AUTHORIZATION CHARGE  

NAME:____________________________________________________________________

ID Card: ___________________________ PASSPORT NUMBER:______________________

CREDIT CARD:                 VISA                     (     )
                                           MASTERCARD    (     )

NUMBER:__________________ VALID:_______________

SECURITY NUMBER: (THE LAST THREE NUMBERS BEHIND THE CARD:_____________

AMMOUNT R$ ( reais ) __________________________

RESERVATION AT COPINHA HOSTEL

PERIOD: From: ____/____/____  To:  ____/____/____

GUEST: _____________________________________________________________

_________________________
GUEST SIGNATURE