Reservation Form
Rates: Double Occupancy $2750.00 Per Person
Single occupancy add $500.00 for total of $3250.00
First deposit of $250.00 per person due upon reservation.
*Reservations are made on a first come first serve basis. There is limited space available.
Final payment due May 1, 2010.
Make Checks Payable to: Monica H. O’Brien OBriensIrishCottage@msn.com
For Reservations Contact: O’Brien’s Irish Cottage
13717 19 Mile Road
Sterling Heights, Mi 48313
(586)-566-9686 Attn: Monica H. O’Brien
Your Name:
Salutation:______ First:____________________Middle:_______________Last:____________________Suffix:______
(Mr., Mrs., Rev.,) (Please print as it appears on Passport) (Jr., Sr.)
Rooming With:__________________________________________________________________________________
( Please print as it appears on Passport)
Your Address:________________________________
Email Address:______________________________________
City:____________________State:______Zip Code:________
Phone:( )_________________________Cell:( )_____-________
Passport Number:____________________
Date of Issuance:________________Expiration Date: ________________
City, State, Country of Issuance:_____________________________________________________________________
Date of Birth:____________________
City, State, Country of Birth:__________________________________________
Gender:________Male ________Female Citzenship:_________________________________________________
Emergency
Contact Name:________________________________
Phone:( )_____-___________________Relationship_________________
I wish to purchase cancellation waiver and insurance at $200.00 per person:_____Yes_____No
(Payment due with first deposit.)
Please note: O’Brien’s highly recommends the purchase of waiver insurance. If you choose not to purchase the Waiver Insurance Plan, you will incur penalties for changes and cancellations (see flyer for more details).
Deposit Amount:$____________Waiver/Insurance Amount:$ ____________Total Amount Enclosed:$ _____________
Please advise your departure airport for this tour:_______________________________________________________
O’Brien’s Irish Cottage accepts American Express Discover, MasterCard, or Visa as payments toward your reservation.
If paying by credit card, please complete the authorization form.
Exploring Scenic Ireland July 8, 2010 – July 19, 2010