CREDIT CARD AUTHORIZTION FORM

Crippen’s Country Inn and Restaurant

239 Sunset Dr. PO Box 528

Blowing Rock, NC 28605

Phone 828-295-3487

Fax 828-295-0388

DATE :___________/_________/___________

I hereby authorize Crippen’s Country Inn and Restaurant to utilize my credit card for any and all purchases.

CREDIT CARD TYPE..(Circle One)______DISCOVER____ MASTER CARD_____VISA

Name of Cardholder_____________________________________________________________________

Credit Card Number____________________________________Expiration Date_______/_______/_____

Billing Address:__________________________________________________________________________

Authorized Signature_______________________________________________________________________

PRINT NAME of Authorized Party___________________________________________________________

Please fill out authorization form and fax back to 828-295-0388 or email to reservations@crippens.com

Thank You,

Crippen’s Country Inn & Restaurant