Overnight and Extended Stay Lodging - Tyler, Texas

EXTENDED STAY APPLICATION

We are also now providing Wireless Internet for your convenience.
Dates Reserved		Arrival Time

Applicant Information
Name
Permanent Address
City
State		ZIP Code
Home Phone		Cell Phone
Social Security Number		Date of Birth
Driver License Number
Smoker	Yes No	Pets	Yes No
Credit Card (Required)	MasterCard Visa Discover American Express
Credit Card Number
Confirmation Number	(On back of card)
Expiration Date	(i.e. 06/09)
Special Instructions

Company Information
Company Name
Address
City
State		ZIP Code
Telephone Number		Fax Number
Contact Name

Bed & Breakfast and Extended Stay Lodging
Tyler Texas - "The Rose Capital of the World"
Located near University of Texas at Tyler
415 South Vine · Tyler, Texas (TX) 75702
Phone: 903-592-2221 Fax: 903-592-5522
E-mail: info@rosevine.com Web site: www.rosevine.com