RESERVATION
REQUEST FORM
Brazil, November 2007
(please print, complete and include with your check)
NAME ______________________________________________________
ADDRESS __________________________________________________
CITY ________________________ ST. ______ ZIP __________________
HOME PHONE ____________________ WORK PHONE ______________
E-MAIL _____________________________________________________
Accommodations:
Price is based upon double occupancy.
__________ TWIN Beds _________ DOUBLE Bed (for couples)
(Single room supplement adds $618.00 to total)
Deposit Information:
Enclosed is my/our check for $______________ ($500.00 per person) as a
deposit to reserve _____ space(s).
Deposits are not refundable after 30 days. Balance due August 24th.
Monthly payments may be arranged.
Credit Cards Accepted.
Print this form and make check(s) payable to:
Mésmera, P. O. Box 291014, Los Angeles, CA 90029 (323) 669-0333
Email: mesmera@mesmera.com