701 A Main Street - Louisville, CO 80027

CREDIT CARD AUTHORIZATION FORM FOR PARTIES OF 11 OR MORE

I hereby authorize ​/por/ wine house ​to use my credit card to pay the deposit for the ____________________________Party of ______ guests on _______________ at __________

(Name for Reservation)                                  (#Of Guests)           (Date)                           (Time)

I understand that /por/ wine house will charge my credit card if I cancel within 48 hours of the

reservation or a “no show”. Deposit Amount= # of guests x $25 ____________

Credit Card Type:

____ Visa ____ Mastercard ____ Discover ____ AMEX Credit

Card Number: ______________________________________________________________________

Expiration Date: ______/_______ Security Code:_________

Cardholder’s Name: _______________________________________________ Card Holder’s Billing Address:

___________________________________________________________________________________

___________________________________________________________________________________

Phone number: ________________________ Email: ________________________________________

By signing this authorization form, you agree to the following: