RENT PAYMENT CREDIT CARD REQUEST FORM:

Give me your Credit Card information by phone, and I will charge your
card using your E-mail address on our secured PayPal account line.

                                or

Print this form & fill out requested information, mail to me at below
address, and I will charge your card using your E-mail address on our
secured  PayPal account line.


Lease: Rena’s Cottage : From_________________________ To_____________________

Amount due $_____________________________________________________

Lease Holders Name:_______________________________, Phone #______________________

Street Address:______________________________________

City:________________________________________________

State:____ Zip Code:__________ E-mail address:______________________

   

 (circle one): MasterCard  Visa  Amex  Discover

Cardholder’s name:__________________________________________

Credit Card(16 digits)__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration Date:_____/_____ (month/year) Security code (extra 3

digits on back): ___ ___ ___

PLEASE COMPLETE AND RETURN TO
I.Glenn Midett
1555 Godfrey Lane
Virginia Beach, VA 23454

Home   Accomodations   Rates & Reservations    House Rules     Rental Agreement   Points of Interest  Credit Card   Location Map