Name: ________________________________________ E-mail: _______________________________

Tel: __________________________________________ Fax: _________________________________

Independent apartment Reference (type and address of apt.): ____________________________________

_______________________________________ Period: From ________________To ______________

Number of persons: __________________________ Number of months: __________________________

Arrival time in Paris: ___________________________ Departure time*: ___________________________

* to arrange an appointment with our agent at the apartment for inspection before your departure.

Total monthly rent including utilities in euro: _____________________________ euro to be debited from my

credit card on file at the beginning of each month for the duration of my stay as specified above.

One month rental deposit: ________________ euro

Optional services:
- Taxi service: Taxi with chauffeur and keys of your rental apartment: YES NO
Airport-Apartment One Way: 70 euro YES Round Trip: 140 euro YES
Rail Station-Apartment One Way: 44 euro YES Round Trip: 88 euro YES
Keys will be picked up at the office of the agency during opening hours: YES
(85, rue de la Verrerie 75004 Paris, from Mon. to Sat. 10am-1pm and 2-7 pm, Mon. closes at 6pm, Sat. opens at 11am)
- Cleaning service during your stay can be arranged, 2 hours/session: 40 euro YES NO

This is to certify that I, __________________________________________________,

hereby authorize ROOTS TRAVEL to debit my Visa / Master Card

Credit Card Number + the three last numbers on the back of the credit card

_______________________________________________________

card billing address ________________________________________________________

expiring on _________________________ for the amount of ___________________ euro

(please include in the amount any optional services you selected above, if any)

as payment of one month rental deposit for my accommodation at (specify type and address of apt.):

_________________________________________________________________________.

In addition, I authorize ROOTS TRAVEL to debit my credit card at the beginning of each month for the amount

of ________________ euro as payment of monthly rent for the period of months of my stay as specified above.

I represent that the premises will be occupied only by myself and my ______________________ guest(s)

arriving on ___________________________ and departing on ___________________________.

I agree that my credit card may also be used as a guarantee against any additional charges (see "conditions"/ "security deposit") that I, or my guests, may incur as a result of our occupancy of the above captioned premises including, missing or damaged property (beyond normal wear and tear).
"Conditions" read and approved.

Signature ___________________________________ Date______________________


RCS : Paris B 410 202 873 (96B 16702) LI No 075970074 / Assurance AXA
No TVA : FR 89410202873 Garantie bancaire: BICS BANQUE POPULAIRE