GA Addiction Counselors Association
Epworth By The Sea • St. Simons Island, Georgia
April 7-10, 2019

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Arrival Date: *

Departure Date: *

Roommate(s) Name:
Roommate other than family please complete separate form

Check box if Roommate will pay separately:

Roommate to pay separately

Number of Adults in Room?

Number of Children in Room?

Number of Teens in Room?

My room is being paid for by:

Special Request (Diet, disability, etc):

*Room Registration is per person per night, and includes meals beginning with supper on day of arrival and goes through lunch on day of departure, and all taxes.
~ PLEASE SELECT FROM THE FOLLOWING ACCOMMODATIONS ~

Turner Lodge

Robertson Inn

Pitts/Booth

Child Rate in room with adult ages 3-12 years: 19.84 per night
Teen Rate in room with adult $45.44

PLEASE INCLUDE TOTAL PAYMENT WITH RESERVATIONS.
If you have a roommate paying separately,
a separate Reservation Form must be filled out and submitted ON THE SAME DAY
Checks payable to Epworth By The Sea

Check #:

Check Amount: $

Or Submit Credit Card Information Below:
Online reservations must be paid for by credit card only

* If you are paying with a State of Georgia credit card and will be tax exempt,
please fill out the Purchase Order Credit Card Authorization Form below.

Credit Card Type

Name on Card

Amount To Charge: $

Credit Card Number

Expiration Date (mm/yy)

3 Digit Security Code:

Billing Address Zip Code:

I am authorized to make these credit card charges:

I Am Authorized

Epworth Cancellation Policy:
Full payment due with reservation by March 20, 2019
Any cancellation after March 20, 2019 will result in forfeiture of $40.00 per person.
Any cancellation within 72 hours of arrival will result in forfeiture of entire per person charge

Please submit this form online, or you may print & FAX to 912-634-0642, or mail to:
Epworth By The Sea
P. O. Box 20407
St. Simons Island, GA 31522
Please email any questions to: lstrande@epworthbythesea.org

* CONFIRMATION OF YOUR RESERVATION WILL BE MAILED OR EMAILED TO YOU *
No phone reservations accepted. No pets or alcohol. Check in: 4:00 p.m. - Check out 11:30 a.m.
This form is for Epworth By The Sea ONLY.

PURCHASE ORDER CREDIT CARD AUTHORIZATION FORM

GUEST NAME:

GROUP NAME:

*Credit Cards must be issued by the State of Georgia. State issued credit cards are tax exempt.
Sales tax and hotel/motel tax exemption forms must accompany this form.
Associations, booster clubs, and personal methods of payments are not tax exempt

CREDIT CARDHOLDER INFORMATION

Name on State of Georgia Credit Card

State of Georgia Credit Card Type

Company Name:

State of Georgia Card Account Number:

Expiration Date:

Billing Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

AUTHORIZED USER OF CREDIT CARD:

Authorized User's Name

Company Name:

Phone Number:

Email Address:

Identification:

Relation to Owner:

Type of Charges:

Authorized Amount:

Dates of Charges:

AUTHORIZATION OF CARD USE

I certify that I am the authorized holder and signer of the credit card referenced above.

I certify that all information above is complete and accurate.

I hereby authorize collection of payment for all charges as indicated above. Charges may not exceed the amount listed above in the "AUTHORIZED AMOUNT" field. I understand this is only for up to this amount during the time period of "DATES OF CHARGES" referenced above. If additional charges are going to be authorized a new form will have to be completed.

Cardholder Name:

Date:

GA Addiction Counselors Association Epworth By The Sea • St. Simons Island, Georgia April 7-10, 2019

*Room Registration is per person per night, and includes meals beginning with supper on day of arrival and goes through lunch on day of departure, and all taxes. ~ PLEASE SELECT FROM THE FOLLOWING ACCOMMODATIONS ~

Child Rate in room with adult ages 3-12 years: 19.84 per nightTeen Rate in room with adult $45.44

PLEASE INCLUDE TOTAL PAYMENT WITH RESERVATIONS.If you have a roommate paying separately,a separate Reservation Form must be filled out and submitted ON THE SAME DAYChecks payable to Epworth By The Sea

Or Submit Credit Card Information Below:Online reservations must be paid for by credit card only

* If you are paying with a State of Georgia credit card and will be tax exempt, please fill out the Purchase Order Credit Card Authorization Form below.

Epworth Cancellation Policy: Full payment due with reservation by March 20, 2019Any cancellation after March 20, 2019 will result in forfeiture of $40.00 per person.Any cancellation within 72 hours of arrival will result in forfeiture of entire per person charge

Please submit this form online, or you may print & FAX to 912-634-0642, or mail to: Epworth By The Sea P. O. Box 20407 St. Simons Island, GA 31522 Please email any questions to: lstrande@epworthbythesea.org

* CONFIRMATION OF YOUR RESERVATION WILL BE MAILED OR EMAILED TO YOU * No phone reservations accepted. No pets or alcohol. Check in: 4:00 p.m. - Check out 11:30 a.m. This form is for Epworth By The Sea ONLY.