ORDER FORM

MOTELGITA
951 S Bascom Avenue, San Jose, CA 95128
Website:www.motelgita.org
Email:info@motelgita.org
Solace for the traveling soul!
Ph: 510-962-2203
NandiniKishori – Florida Regional Director

Date: _______________ Venue: _________________________________________________

Your Name

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Motel Name

Motel
Address, city,
state, ZIP
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Rooms (Refill?)

If you have multiple motels,please fill out following section.

Motel Name

Motel
Address, city,
state, ZIP
Number of Remarks
Rooms

Any Donation Amount: ____________ Cash / Check /Credit card

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Signed By Motelier :

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