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)

Title 

(Miss, Mr, ME)

First name, Name *

(your name)

E-mail * 

(your@email.com)

Phone *

(your home phone number)

Fax 

(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  

(select)

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)

  MC VISA AMEX   

 

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.