Reservation
Please print this form and return it by fax at 1 (819) 333-9106, thank you! Toll free: 1 888 417-3767

The asterisk (*) indicates a required field, before printing the form.
PERSONAL INFORMATION
Sir Madam
Name*
Given Name*
Email Address
Information Company Personal
Name of the company
(if necessary)
Address
City / Town
Province / State
Country
Postcode / Zip Code
Telephone Number*
Fax
Message



PAYMENT INFORMATION
Credit Card
Credit Card Number
Expiry Date



ROOMS*
Select Room Regular Room

Two Queen beds (2nd floor)
One therapeutic bed
Queen bed, living room impression (pull-out bed on the 2nd floor)
Bridal suite, double whirlpool bath

 One double bed
Two double beds
Single whirlpool bath



ADDITIONAL INFORMATION
Date of arrival*
Time of arrival
Date of leaving*
Number of rooms*
Do you wish to have a room for a mobility-impared or handicapped person? Yes No
Type of room* Smoking Non-Smoking
Number of children
Number of adults*
Particular equipment requested
(Ex: Folding bed, child's playpen)
Package



   
Signature* _______________________        Date (Day/Month/Year)

Please print this form and return it by fax at 1 (819) 333-9106. Thank you!