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					                             Hotel Reservation Credit Card Authorization Fax Sheet
                                                   UW-Madison Purchasing Card Program
                                           21 N. Park Street, Suite 5301, Madison, WI 53715-1218



This letter authorizes (hotel)
located in
to charge the University of Wisconsin-Madison Purchasing Card for the following:
   Room, tax, parking, internet access, and business call only
   Room, parking, internet access, and business calls only—Letter for Sales and Use Tax Certificate of Exempt
Status will also be faxed (http://www.uwsa. edu/ fadmin/fppp/fppp36i.htm ).

The maximum allowable single room rate per day for this location cannot exceed. $
All additional charges are to be billed to the traveler.

     Guest Name(s)                    Confirmation                 Arrival Date                  Departure Date




Conference or Group A ffiliation:

                                       US Bank VISA Card Information

Credit Card Number:

Credit Card Expiration Date:                                                   3-Digit Security Code:

Cardholder Name:

Company Name:

Billing Address:

E-mail Address:

Telephone:                                                        FA X:


                                 Cardholder Signature                                                  Date


   Insert copy (photocopy or scanned image) of front of the   Insert copy (photocopy or scanned image) of back of the
                   signed credit card here.                                   signed credit card here.




e2683cb7-21f5-4c82-ba57-a14ea3147778.doc                                                         Last updated: 4/7/2011

				
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