Please FAX to 402-768-6529

Today's Date: __________________________________________________________

Guest Name: ___________________________________________________________

Arrival Date: ________________________  Departure Date:______________________

Phone: (        ) _______________________  Fax : (        ) _________________________

Address: ______________________________________________________________
(Please check one)
                                Number of Guest:_______     Number of Rooms    ________
                                          Single Bed _______     Double Bed               ________      
                                   Smoking Room _______    Non-Smoking Room ________

Method of Payment (Credit Card Number required to guarantee your room)
VISA/MC/Other_____________                 
Card Number

Expiration Date

                                                  Signature  X _________________________________________
        (I authorize Budget Host Inn-Hebron to guarantee my reservation with my credit card)

Special Request  _________________________________________________________________

______________________________________________________________________________

Confirmation Needed by _____________ 

Guest's FAX # for Confirmation (            )____________ ________________

(This section is to be completed by Budget Host Inn and faxed for guest)
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Confirmation No. ____________ Room Rate $______________  Confirmed by ______________