Please print and email ( firstname.lastname@example.org ) after filling in full.
I, ____________________________(print your name) authorize Attican Motel, 11180 Alexander Road, Attica, NY 14011 to apply charges of Room rent + taxes as applicable USA $_______________________ to my credit card (call 585-591-0407 to enter the amount).
Guest name____________________ (ID must be presented at check-in).
Arrival date:_________________. Departure date:_________________.
Type of Room:
1. Select any one A or B from below and enter here:______
A. Single Room with single bed.
B. Double Room with double bed.
2. Select any one C or D from below and enter here:______.
Enter number of people staying in a room:
Adults (12 years and up) _______. Children (under 12 years)_______ Total_______.
Pets (charges apply)
None _______. Yes___________ . Number of pets_________
I agree to pay as per the credit card holders agreement for the above reservation.
Name of the Card Holder______________________
Expiration date_______________ Digit code* on card___________
*On Visa/Mastercard/Discover it is three or four digit on the back of the card. On American Express it is the number above your credit card numbers on the front of the card.
Card holders billing address ________________________________________________.
City______________ State________________ Zip Code___________
Phone ___________________________. Email______________________________.
I agree that full amount will be charged at the time of making this reservation.
This reservation is non-refundable and cannot be changed, cancelled or transferred. In event of no show, no refunds will be made. Initials _______.
Your signature below will constitute a binding agreement for full payment for the above specified charges for room accommodations by guest.