| Date of Arrival |
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| Date of Departure |
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| Number of Nights |
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| Name |
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| Drivers License Number |
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| State |
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| Address |
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| City |
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| Zip/Postal |
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| Country |
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| Email |
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| Phone Number |
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| Fax |
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| Primary reason for staying in the Las Penitas area? |
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| How did you hear about My Nica House? |
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| Persons in your Travel Party (including yourself) Please list Title, Last Name, First Name, and Age |
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| We will require the pool to be filled prior to our arrival |
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| We will require a late check out at 1 p.m. on the day of departure (US$25) |
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| I have read, understand and accept all of the terms and conditions * |
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