AT HOME IN MONTMARTRE

PARTICIPANT INFORMATION

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Name AS IT APPEARS ON YOUR PASSPORT

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Address

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City, State, Zip Code

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Home Phone - Home Fax - email

I am enrolling in the __ April 11 - 17 __ May 9 - 15 __ Sept 5 - 11 tour.

I am requesting: (single occupancy) (double occupancy*)

with (Please submit a separate enrollment form for each participant in Double Occupancy, except for married couples) _________________________

MY CHECK for $1,000 made payable to Chez Madelaine is enclosed.

Please mail to 425 Woodside Ave., Hinsdale, IL 60521.

I WISH TO CHARGE a $1,000 deposit

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CARD NUMBER - EXPIRATION DATE - SECURITY CODE

(A 4% charge will be added to cover processing fees, VISA/MASTERCARD ONLY PLEASE)

My SIGNATURE indicates that I have read and agree to all of the following Terms and Conditions of this travel program.

______________________________________ _________________________ SIGNATURE DATE

Direct questions to Madelaine by telephone: 630-655-0355 or email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it