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Beachside Poipu Hale
Secure Payment Form

(All fields required - put "none" if applicable)

Your Name:
Your Email:
Your Phone Number:
Number of people in your party:
Villa or Suite Paying for:
Check-in Date: Check-out Date:
Date format to use: mm/dd/yyyy

Amount to charge against card: (US)
CARD TYPE
VISA MasterCard
Name on Card:    
Card Number:
3 digit security code:
Expiration Date:      
Billing Address:  
City
State
Zip Code
Country        

Special Questions or Comments:


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Beachside Poipu




Call us Toll Free 1-888-743-1331
local number 1-808-651-5652

Email kathleen@beachsidepoipu.com


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