First Guest, First Name:    First Guest, Last Name:  

Second Guest, First Name:    Second Guest, Last Name:  

Street Address:    Apt #:  

City:    State/Province:    Zip or Postal Code:  

Country:                        Room Type:   Make a Selection Non-Smoking Double / Ocean Front: $300pp Dep./Bal. $825pp. Smoking Double / Ocean Front: $300pp Dep./Bal. $825pp. Non-Smoking Single / Ocean Front: $300 Dep./Bal. $1,295. Smoking Single / Ocean Front: $300 Dep./Bal. $1,295. Non-Smoking Double / Ocean View: $300pp Dep./Bal. $575pp. Smoking Double / Ocean View: $300pp Dep./Bal. $575pp. Non-Smoking Single / Ocean View: $300 Dep./Bal. $950. Smoking Single / Ocean View: $300 Dep./Bal. $950.

Method of Payment:    Check/Money Order    Credit Card  Credit Card Number:   Expiration Date (mm/yy):

Credit cards accepted by Country Hills Travel are:  The American Express family of cards, The Novus/Discover family of cards, MasterCard and VISA, and Bank ATM/debit cards co-branded with these card logos.

Name as embossed on the card:

If using a Credit Card:  I authorize Country Hills Travel to charge the amount of $ to the credit card whose number I have entered above.

Telephone:     E-mail address:  

(Please include your telephone country and city codes if outside the United States, Canada, or Puerto Rico).

Please note:  All fields above are required in order to sign-up or make a payment.

Regarding Trip Cancellation/Interruption Insurance, I   Make A Selection Choose to Accept the offered product. Choose to Decline the offered product. desire more information, please contact me. am just making a payment on my balance.

By initialing this box, I certify that I have read and agree to the group Terms & Conditions.  

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