The Gumbo House         

Rental Application                           

PERSONAL INFORMATION

Name: ________________________________________________

Date: _________________________________________________

E-mail: ________________________________________________

Telephone: _____________________________________________

Present Address: ___________________________________________________

City/State/Zip: _____________________________________________________

OTHER INFORMATION:

What dates do you wish to stay at the Gumbo House?  _______________________

How were you referred to us? _________________________________________

How many in your party?  Adults ______________      Children _______________

Number of vehicles staying at the house?  Make & Models?

__________________________________________________________________

CREDIT CARD INFORMATION                        FEES

Type: ______________________________                Rent: _________________

Number: ____________________________               Cleaning Deposit:  $100

Exp. Date: ___________________________              Security Deposit:  $250

*If you cancel your reservations within 7 days prior to your stay, there will be a non-refundable $250 fee.  To reserve your dates we charge 1/2 the total fees upfront, and the remaining 1/2 when you stay.

Applicant's Signature: ____________________________________________

By signing the application you are acknowledging that you have seen and read the Rental Agreement.

If you have any questions, please call or email Leia or Carol at:

thegumbohouse@welcome2m.com  or call us at 541-389-9000

Please fax application to 541-382-0096