Escape Factor Authorization Form
For use when card holder will NOT be present for a booking. Please use the SAME credit card used to pay for the original reservation.
I certify that I used my credit/card on the following date:
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-
Month
-
Day
Year
Date of original authorization
in order to make a non-refundable reservation at Escape Factor to take place on the following date:
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Month
-
Day
Year
Planned date of event
For the following starting time:
*
Start Time of Event
In the amount of:
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USD ($)
on my credit/debit card ending in:
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Last 4 digits of card ONLY
Since I will not be present during the time of the event, the following person is authorized to utilize the reservation created from this card authorization:
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Cardholder Phone Number
*
Cardholder Email Address
*
Please take a photo of cardholder's official state ID (must display signature)
ALTERNATE: If you do not have an attached camera, please upload an image of the cardholder's official state ID instead
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Please take a photo of credit card used (last 4 digits MUST be visible.. please block the other digits if you like)
ALTERNATE: If you do not have an attached camera, please upload an image of your credit card instead (4 digits visible)
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Please take a photo of YOU holding BOTH your ID and CREDIT CARD towards the camera
ALTERNATE: If you do not have an attached camera, please upload an image of you holding BOTH your ID and CREDIT CARD towards the camera instead
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My name (as appears on card)
*
Today's date
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-
Month
-
Day
Year
Date
I CERTIFY that I am the owner of the card described above. I ACKNOWLEDGE that this is a NON-REFUNDABLE transaction, regardless of the attendance of any or all of the participants on the event date. I AGREE that i will not dispute the amount, authorization, or transaction with my credit/debit card company/bank. FINALLY, I AGREE that this document can be used against me in case of an official dispute. Any fraudulent use of a credit/debit card will be forwarded to the appropriate authorities and will result in a permanent ban at ESCAPE FACTOR. My signature indicates the acceptance of the statements above.
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Submit
Should be Empty: