This non-refundable $100 will be applied towards first month's rent.

Name________________________________________________________________________________

Permanent Address_____________________________________________________________________

City/State/Zip__________________________________________________________________________

Phone________________________________________________________________________________

Current Address (if different)______________________________________________________________

City/State/Zip__________________________________________________________________________

Phone________________________________________________________________________________

Send deposit with this form to:
 

    John & Jody Holand
    10166 160th St NE
    Thief River Falls, MN 56701

Room choices will be made by the order this form & deposit are received.

Date received__________________________________________________________________________