Mr. Mrs. Miss
Last Name

First Name

Address

City

Province/State

Postal/Zip Code

Country

Home Phone #

Business Phone #

E-Mail Address


Type of Rooms Required:

Type A, Fully furnished, large Bed, 2 separate Tel No., large             bathroom.
Room Studio Type B, Kitchenette, Shower Bathroom, fully furnished.

Number of Rooms  required:
Room Type A
Room Studio Type B
Suite Type C

Check in Date
Check out date

Other comments:

Method of Payment
Credit Card Money Order Check

Credit Card Type



Credit Card Number

Expiration Date

Name on Credit Card