Colonial House

17544 Hwy #7, RR-4, Perth, Ont, K7H 3C6 Tel: 613-267-3660, Fax: 613-264-2896

Third Party Credit Card Payment Authorization Form

This form serves as a credit card authorization receipt for Colonial House Motor Inn. By signing this document, the customer gives full authorization to Colonial House Motor Inn to process the charges for the total number of room’s rented and any other phone charges for incidentals that may occur to specified credit cards that will not be present at time of Check-in. A photocopy of the front and back of the Credit Card is required, with a valid Photo ID of the Credit Card Holder. Please attach a legible copy of credit card, and Driver Licence along with this document and submit it at the bottom of the page. Guests will not be permitted to check in without prior authorization of these documents.

Company Name:
Telephone No:
Fax No:
Guest Count:
Credit Card No:
Expiry Date:
3 or 4 Digits CVC Code:
Billing Address:
Postal Code:
No of Nights:
No of Rooms:
Rate / Day:
Confirmation No:
Arrival Date:
Cardholder's Name:
Email ID:
Upload Credit Card Front:
Upload Credit Card Back:
Upload ID Card Front:
Upload ID Card Back:

Cancellation Policy:

48 hours cancellation notice is required prior to the arrival date. Otherwise a charge will be processed to the credit card listed above for the first night at full rate.