Booking Form Personal DetailsFirst Name Last Name AddressAddress Line 1 Address Line 2 City State Postcode or zip code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmail Home Telephone Mobile Telephone Holiday DetailsPlease use a separate booking form for each cottageCottage - Select -FermierLes CedresGuiliettaLes IrisLes RosiersArrival Date Departure Date Bookings are from 4.00pm on the arrival date to 10.00am on the day of departure. Please indicate likely time of arrival How did you hear about Peyloubere? Baby/Toddler equipment required CotHighchairBaby bathToy ChestOther Requirements Names of others in your partyName Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Name Age - Select -AdultTeenagerChildBaby Payment DetailsTotal cost of holiday € Booking Deposit (20%) € Deposit is being paid by - Select -Credit CardEuro ChequeBank Transfer By credit card - MasterCard, Visa or Carte Bleu. Please advise card number, expiry date and three digit security code. We suggest that this information is conveyed to us by telephone or by way of two separate Emails. By cheque - if you wish to pay by Euro cheque please make the cheque payable to 'Theresa Martin' All cheques should be sent to Theresa Martin at Domaine de Peyloubere, 32550 Pavie, France By bank transfer - please request bank details We regret that deposits are non-returnable. Please ensure that you have health and holiday insurance at the time of booking, which should include loss of deposit through cancellation. By submitting this form you declare, on behalf of the persons named above, that you have read and agree to the Self Catering Booking Conditions and agree to pay the balance of the cost of the holiday, together with a damage deposit of €200, at least six weeks prior to the start of the holiday. Submit Form