Name   ___________________________________________________________________

Mailing Address __________________________________________________________

City ______________________________  State __________    Zipcode _________

Telephone _________________________  Fax _________________________________

Arrival Date ______________________  Departure Date ______________________

Number in Party _____  ___ Single/Double ___ Gov. Single  ___ Gov. Double

                       ___ Smoking  ___ Non Smoking

List All Room Occupants __________________________________________________

Special Requirements _____________________________________________________

Reservation Guarantee:

   ___American Express ___Diner's Club ___Master Card ___Visa  ___Discover

Credit Card #___________________________ Exp. Date _______________________

Signature ________________________________________________________________

Fax this form directly to the reservation department at 412.553.5193.