<BGSOUND SRC="http://villabelmar.com/Cielito.mid" LOOP=INFINITE>


   Today's Date:      /       /   



   
From: (name)_____________________________________________________


   
Postal address____________________________________________________

                              ___________________________________________________________________
                             
                               _______________________   
   Country_________________________

   
e-mail address:________________@_________________

  
Telephone Number:__(_____)-____________________
   Request :________________________________________________________
                _________________________________________________________
                _________________________________________________________
                _________________________________________________________
                _________________________________________________________
                             _________________________________________________

     
   
Amount Autorized to Charge to my Card $_________US Dollars
 

Signature_____________________________      Date        /          /
                                                                                 DD     MM  YEAR 

     
Card number
    
     GOOD THRU____ /____


     BILLING ADDRESS______________________________________________
                                    _______________________________________________
                                    _______________________________________________
                                   ________________________________________________

Fax to:VILLA BELMAR
                      
Hotel & Beach Club
USA& CANADA Fax number  
(1)  954 317 3312
(USA-CAN  -IT IS A USA. NUMBER)
                                                  
FROM ANY COUNTRIY ALSO DIAL
(INTERNATIONAL ACCESS  CODE ) 52 954 582 2520