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Credit Card Payment Authorization Form

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For your convenience, Boston Homestay Inc. can accept either VISA or MasterCard credit card payments. Please PRINT a copy of this page, complete the form and fax it back to Boston Homestay Inc.

The Boston Homestay Fax Number in the USA is (781) 455-1153

Your Name: ___________________________

Home Address: ____________________________________________

City: _______________________, State: ____________________

Postal Code: ________________, Country: __________________

Telephone Number:_____________________ Fax Number: ___________________________

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Check One: VISA_____, or MasterCard______

Name on Card
(if different from above):______________________________

Card Number: ___ ___ ___ ___ -- ___ ___ ___ ___ -- ___ ___ ___ ___ -- ___ ___ ___ ___

Expiration Date
(format mm/yy): ___ ___ / ___ ___

I do hereby authorize Boston homestay Inc., to charge $__________ to the above VISA/MasterCard Account for homestay placement services.
I agree to notify Boston Homestay Inc. directly should I have any intention of extending my homestay beyond the agreed upon date. Furthermore, I authorize Boston Homestay to charge my credit card at the agreed upon weekly/monthly rate should I decide to extend my homestay, or return back to this homestay, for any reason.

Signature: ___________________________________, Date: _________________
(required when returning form by fax)

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