Date:

Passport #:

Country:

I,

Print Full Name as shown on VISA Card

Telephone:

Fax / Cell:Fa

DEPOSIT Amount in US $

VISA Number:

VISA Card Expiry Date:

P L E A S E   P R I N T

I hereby agree as the "Conditions of Reservation" to pay the amount here authorized as a "No Show Deposit" even though I did not sign the charge note original voucher. I hereby authorize AparHotel Vista Pacifico (GreJanBerTil S.A.) to charge the "No Show Deposit" to my Visa and if I do not arrive at the hotel on the date of my Reservation, for any reason, there shall be no refund.

Signature (Exactly as on Card)

X

Print this form - Fill it in with a Signature and Fax to 011 (506) 2643-2046. or
E-mail a Signed Word .Doc / .PDF / .JPG to janandgreg@vistapacifico.com

Arrival Date	Departure Date	Type of Room / Number	Total Amount in $ US

www..com
Hotel VISTA PACIFICO, Apdo 108-4023, Jaco, Puntarenas, Costa Rica •
Tel: 011 (506) 2643-3261 • Fax: 011 (506) 2643-2046
GreJanBerTil S.A.• Lomas de Jaco • Ced. Jur. 3-101-270858 • ICT 611-136 • IV 3-120-056802-28