Cocobay Credit Card PAYMENT Authorization Form

I hereby authorize Cocobay Resort to CHARGE the card indicated in this authorization form according to the terms outlined below:

Name (As Shown On Credit Card): *

First

Middle

Last

Reservation Reference No. (If Available)

Email *

Credit Card Type: *

Visa
Mastercard
Amex
Discover

Credit Card No.: *

Exp Date: *

Security Code (CVV): *

Amount US$:

Credit Card Image Upload ( Front & Back ) *

Click or drag files to this area to upload. You can upload up to 2 files.

Proof of Identification (Name Must Match Credit Card) *

Click or drag a file to this area to upload.

Authorized Signature: *

Clear Signature

By signing above, I certify that I am an authorized user of this credit card and I will not dispute the charges with my credit card company, so long as the transaction corresponds to the terms in this form or Cocobay Terms & Conditions.

Phone