Credit Card Authorization Close To Stay

Name *

First

Last

Date / Time *

Date

Time

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reservation & Authorized Amount

Reservation Number *

Authorized Amount *

Card Information

Credit Card Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Credit Card Information

Last Four Digets of the Credit Card *

Verification Code *

Last 3 digets on the back of MasterCard, Visa, Discover or the 4 digets printed on the front of American Express

Photo of Card Holder Drivers License *

Click or drag a file to this area to upload.

Drivers License must match the name on the card the billing address and the address on the reservation

I hereby acknowledge and agree to the total charges for my stay as indicated. By signing below, I confirm that I have thoroughly read, understood, and accepted the Terms and Conditions provided by Glass Casa Vacations for my reservation. Furthermore, I authorize Glass Casa Vacations to charge the credit card provided above for all costs associated with my vacation accommodations and any additional incurred charges.

Signature *