8279 Santa Monica Bl., West Hollywood, CA 90046

Tel.(323) 822-3300  Fax(323) 822-3330

E-mail info@obarrestaurant.com

CREDIT CARD AUTHORIZATION FORM

I, (print name) ________________________________________________

authorize O-Bar Restaurant to charge my credit card account referenced below.

All information will be held strictly confidential.

Guest Name: _________________________________________________

Contact phone number: _________________________________________

Date of Event: ____________________

Company: ___________________________________________________

Billing Address: _______________________________________________

Purpose of Charge: ____________________________________________

Type of Card: Visa M / C AMX DSCV

Card Number: ____________________________ Expiration Date: _________

Name on Card: _________________________________________________

I have read the above and authorize the use of my credit card for purchases from O-Bar Restaurant.

Authorized Signature: ____________________________ Date: __________

This authorization must include LEGIBLE copies of front and back of credit card and a copy of valid photo ID.