Reservation form for MT CHASE LODGE
Please call to confirm available vancancies

:Mail or fax this form to

Fax(207) 528 - 2479

Mt Chase Lodge
1517 Shin Pond Road,
Mt Chase, ME 04765

Name_________________________________________________________________________

Address_______________________________________________________________________

City________________________ State_______________ Zip____________

Phone(day)___________________ Phone(evening)_____________________

Email Address__________________________________________________

Date of arrival______________________ Date of Departure____________________

Accommodations Requested check one, ( American plan main lodge,______ Housekeeping Cabins_______)

#Adults_______ #Children under 16______

Pets (additional charge)________________

Special requirements, dietary etc.____________________________________________________________

_____________________________________________________________________________________

Deposit enclosed, $___________________

Credit Card, Master Card_____ Visa_____ Discover_____

Credit card#__________________________ Expiration date______________

Signature____________________________________

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