Motel des Pays d'en Haut's Secure Reservation and Inquiry form

please record my following RESERVATION
please send me an OFFER 

(examples for your responses)


(Miss, Mr, ME)

First name, Name *

(your name)

E-mail * 


Phone *

(your home phone number)


(your fax number)

Number persons *

(2 adults, 2 kids, etc.)

children's ages *

(23 months, 12 years, )

Number rooms needed  *

(one with 2 beds)

Arrival date and time  *

(Feb, 02 2005, 18h00)

Departure date  *

(Feb, 09 2005)

Room category *

(2 beds, SPA, Fireplace, etc..)

Special you provide for  


Comments or
subjects of offer

Please write down your comments, additionally questions, the subjects of offers, etc.
* For a reservation or offer this fields must be completed.
Name and E-Mail fields are obligatory.

To register a reservation we need your Credit Card information:
(only needed for reservation)



Card No :                   
Ex : 1234 4321 0000 1234   

 Expiration date :
month and year (select)

3-digit Security No :                   
Ex : 088 last 3 digits of CC no.
 on the backside of your CC)

Name on the card:

card holder)  

Note : This form uses SSL secured file transfer. Your personal data can't be visualized by non authorized persons !

With this form you transfer also your IP-Number and your Host-Address.

(to return to the previous page, click on the return button)

(C) Copyright 2004- by 2640-7999 Quebec inc.