countryinn

1815 East Madison
Bastrop, La 71220
Ph.  (318) 281-8100
Fx.  (318) 281-5895

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American Owned
and Operated

              

 

Home Rooms/Rates Reservations
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Reservation Form

Please complete this form to submit your reservation request.
Our staff will confirm your reservation by telephone within 24 hours.
Please DO NOT send any credit card information.
* = Required Fields


Name*

First
Last
Address*

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number*

###		-
###		-
####
Email*
Check-In Date*

MM		/
DD		/
YYYY
Check-Out Date*

MM		/
DD		/
YYYY
Number in Party
Smoking Room?
 Yes 
 No 
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Keller Williams

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info@countryinn-motel.com