EPWORTH BY THE SEA
GA Addiction Counselors Association
April 26 - 29, 2018
A SECURED PAGE FOR EPWORTH BY THE SEA
Your Name
Address
City     State     Zip Code    
Phone       Email    
*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. View Accommodations at: epworthbythesea.org/accommodations
Please check applicable rate:
LODGING
SINGLE
OCCUPANCY
DOUBLE
OCCUPANCY
TRIPLE
OCCUPANCY
QUAD
OCCUPANCY
TURNER LODGE
$165.70
per person per night
$113.66
per person per night
$94.39
per person per night
$85.91
per person per night
ROBERTSON INN
(FULL - NO AVAILABILITY)
$154.18
per person per night
$104.44
per person per night
$84.02
per person per night
$80.15
per person per night
PITTS/BOOTH
$143.81
per person per night
$97.53
per person per night
$78.26
per person per night
$75.54
per person per night
Child Rate in room with adult ages 3-12 years: $19.30 per night.
Teen Rate in room with Adult: $44.33 per night
Roommates Name:     Check box if Roommate will pay separately
Special Request   (Disability, diet, etc.)
Arrival Date Departure Date
Number of Adults in room:
Number of Children in room:
Number of Teens in room:
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.
Make check payable to Epworth By The Sea.
Check #    Amount: $   
OR
* Charge to:    Visa      MasterCard       Discover      Amount to Charge: $
* 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.
Card Number:        Expiration Date:
Name on Card:       
CVV Code:     Billing Address Zip Code:
 Check here to affirm that I am authorized to make these credit card charges
Epworth Cancellation Policy:
Full payment due with reservation by April 13, 2018.
Any cancellation after April 13, 2018 will result in forfeiture of $20.00 per person. 
Any cancellation within 72 hours of arrival will result in forfeiture of entire per person charge.
Please submit this form online, 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,
No phone reservations accepted. No pets or alcohol. Check in: 4:00 p.m. - Check out 11:30 a.m.
* CONFIRMATION OF YOUR RESERVATION WILL BE SENT TO YOU *
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 CREDIT CARD:  
TYPE OF CREDIT CARD:   Visa     Mastercard     Discover
COMPANY NAME:  
ACCOUNT NUMBER:  
EXPIRATION DATE:  
BILLING ADDRESS:  
CITY:       STATE:     ZIPCODE:
PHONE:       FAX:
AUTHORIZED USER OF CREDIT CARD:
NAME:  
COMPANY:  
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: