First and Last Name_______________________________________________________________________________

Address_________________________________________________________________________________________

City______________________________________State_______________________ZIP/Post Code_______________

Country_________________________________________________________________________________________

Email___________________________________________________________________________________________

Confirm Email____________________________________________________________________________________

Telephone______________________________________ Fax_____________________________________________

Card   Visa [ ]     Mastercard [ ]   America Express [  ]

Card Number___________________________________________________________________

Cardholder's Name________________________________________________________________________________

Expiry Date ______/________

Signature_____________________________________ (Required)

Birthdate______________________________________(Required)

    Accommodation                  Arrival Date               Departure Date               N. Guests

     ___________________    _________________    __________________       _____________

     ___________________    _________________    __________________       _____________

Special requests:

_____________________________________________________________________________________________

Reservation Form Via Fax/Mail

Print it and Fax it to +1-347-287-6830 or mail it to info@romeescape.com