SERENITY COTTAGE RESERVATION FORM

Arrival:     Departure:   No. Nights:

(Revised) Arrival:      Departure:   No. Nights:

Title: Mr. Mrs. Ms. Mr./Mrs.   Last Name:   First Name:

Address1:   Address 2:

City: State:   Zip:   Country: 

Telephone:     Fax:     email address:

ACCOMMODATIONS REQUESTED

Room:  Studio 1 Bedroom Suite 2 Bedroom Suite    Special Request: Ground Floor Second Floor 1st and 2nd Floor

No. Persons:    No Adults:   No Children:   Ages:

Car Rental: Yes No Describe:    Groceries:  Yes No Type:

Credit Card Information for deposit 

(Please note this is not submitted over a secure server.  You may also fax credit card information to:  264-497-3867)

Deposit Paid by: Check Credit Card

Card Type: Amex Visa M/Card   Card No:   Exp. Date:

Name On Card:

Booked By:

Name of Agency:

Address:

Address 2:

City:   State:   Zip:   Country:

Tel. No:   Fax No:  Agency email: