| Today's Date: From: (name)_____________________________________________________ Postal address____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ e-mail address:________________@_________________ Telephone Number:___________________________ Request :________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ _____________________________________________ ONLY IF YOU ARE GOING TO MAKE A DEPOSIT USING CARD Card number : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ GOOD THRU: / SECURITY NUMBERS: _ _ _ CARD BILLING ADDRESS________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ |
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| (MARK ONE) |
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| Fax to: VILLA BELMAR BeachHotel Fax (1) 954 317 3312 (USA&CAN.) FROM OTHER COUNTRIES , ENTER ALSO YOUR INTERNATIONAL ACCESS CODE |