Reservation Request Form Check-In Date:   05/19/2012 No.Nights 7 No.Adults   No.Children  First    Last     Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY QC ON NS (Canada use QC,ON,NS at bottom of list) Breakaway 122-Bldg 2 1st flr - Courtyard View Zip Day Phone Cell Phone E-Mail Remarks How did you find Siebert Realty? Repeat guest Friend/Relative Postcard in Mail Email Brochure in Mail Brochure from Virginia Welcome Station Internet Search Engine (ie Google,MSN,etc..) Internet Link (on another website) Newspaper Ad in: Other: Estimated Cost Arrive:05/19/2012 Rental Charge for 7 Nights : 550.00 Reservation Fee : 60.00 Accidental Damage Protection : 75.00 Sales Tax : 34.25 City Tax : 71.93 ---------- Total Charges : 791.18 Optional Travel Insurance Travel Insurance : 54.99 ---------- Total Charges w/Options : 846.17 E-Mail confirmation letter? No   Yes Enter security number: Conditions of Reservation Request- Submission of this form constitutes a request for Siebert Realty to place a reservation in your name for the above mentioned property and check-in date. We are instructed by our owners to rent to Family Groups Only. Fraternal, sorority, student or single groups are asked not to apply for accommodations. The leaseholder must be at least 24 years old and understands that he/she must personally occupy the property for the entire period. We lease homes without respect to the race, color, religion, sex, national origin, handicap or familial status of any party. Your request submission acknowledges you are a qualified group. Siebert Realty does not guarantee availability of the property nor does submission of the form confirm a reservation. All reservation requests will be processed in the order in which they are received. Thank you for placing a Reservation Request with Siebert Realty and we look forward to seeing you at beautiful Sandbridge Beach.

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Siebert Realty - Established 1962 - 601 Sandbridge Road Virginia Beach, VA 23456 Toll Free (877)422-2200 - (757)426-6200 E-Mail: mail@siebert-realty.com