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THE PALMS RESTAURANT

CANCELLATION POLICY

$200 cancellation fee applicable if for any reason the event is cancelled.

___________________________
Print Name

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Signature

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Date

Type of Credit Card: AMEX MASTERCARD VISA

Card Number: ________________________________________________________


Expiration Date: __________________
Security Code: ___________
Name of Appearing on Card: _____________________________________________
Amount to be Charged: _____________________
Date/Time of Event: _____________________________
Event Detail: _________________________________________________________
Cardholder's Telephone Number: ___________________________

I AUTHORIZE AND UNDERSTAND THE FOLLOWING: The Palms will charge the above stated
amount to my stated card for the purchase noted. This deposit or purchase is nonrefundable or
transferable. I have attached a copy of this card.

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Cardholder/Name Print

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Cardholder/Name Signature

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Date