Please call to confirm available vancancies - (207) 528-2183
Mail or fax this form to:
Mt Chase Lodge
1517 Shin Pond Road,
Mt Chase, ME 04765
Fax (207) 528 - 2479
Name________________________________________________________________________
Address______________________________________________________________________
City_________________________________ State_______________ Zip_________________
Phone(day)___________________________ Phone(evening)___________________________
Email Address_________________________________________________________________
Date of arrival__________________________ Date of Departure_______________________
Accommodations Requested (check one)
# of Adults_______ # of Children under 16 ______
Pets (additional charge) ________________
Special requirements, dietary etc.________________________________________________
____________________________________________________________________________
Deposit
Amount $___________________
(Enclose Check or provide Credit Card Info below)
Credit Card: Master Card____ Visa____ Discover____
Credit card #________________________________________
Expiration Date_________________; Security Code_________
Signature______________________________________________