First Name:
Last Name:
Nationality:
Telephone:
Fax:
E-mail:
Arrival:
Departure:
Adults:
Children under 4 years:
Children 5-12 years:
To confirm your reservation we need a credit card number:
Type of Card:
Account #:
Expiration Date:
Please give us the last three digit on the back of your Card:
Amount $
Will you need the pick up shuttle service?
If you will, please give us your flight details:
Airlines Company:
Flight Number:
Arrival time(Costa Rican Time):
The flight is coming from:
Any aditional request:
Credit card charge Authorization form by fax
In order to confirm my reservation, I authorize the Hotel Berlor to charge my credit or debit card for the total amount of my reservation.
