Registration Request Form

Please provide the following information:
        * is a required field

CONTACT INFORMATION
Contact Name	*
Reservation Dates:	*
Number of Persons:	*

NAMES
Name:
Name:
Name:
Name:

ADDRESS
Email Address	*
Street Address	*
Address (cont.)
City	*
State/Province	*
Zip/Postal Code	*
Country	*
Phone number	*  xtn:
Fax Number

BILLING
Note:  A VISA or Mastercard credit card must be on file.
Payment Type	VISA Mastercard Cheque Money Order Cash *
	Do not send cash in the mail. Cash can only be  accepted in person as we do not have INTERAC© direct payment set up.

If paying by VISA or Mastercard, please contact us directly at:

1-604-552-0496   

If mailing cheques, please make payable to:

Linda Cook

Our Mailing Address:

78038 - 3295 Coast Meridian Road
Port Coquitlam, B.C. CANADA   V3B 7H5