GA Addiction Counselors Association
Epworth By The Sea • St. Simons Island, Georgia
April 7-10, 2019
Address Line 2
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 ~
Single Per Person Per Night: $169.10
Double Per Person Per Night: $117.06
Triple Per Person Per Night: $95.49
Quad Per Person Per Night: $87.01
Single Per Person Per Night: $157.58
Double Per Person Per Night: $107.85
Triple Per Person Per Night: $85.13
Quad Per Person Per Night: $81.25
Single Per Person Per Night: $147.21
Double Per Person Per Night: $100.93
Triple Per Person Per Night: $79.36
Quad Per Person Per Night: $76.64
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 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
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: email@example.com
* 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
*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
State of Georgia Card Account Number:
AUTHORIZED USER OF CREDIT CARD:
Authorized User's Name
Relation to Owner:
Type of Charges:
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.