1416 S. Third St.
Louisville, KY 40208

(502) 636-0409
(800) 303-0053
(502) 636-9157 FAX

Email Us!

The Bernheim Mansion
Bed and Breakfast

Registration & Credit Card
Payment Form

Thank you for choosing the Bernheim Mansion Bed and Breakfast.   We're looking forward to having you as our guest!

Confirmation Number (if known)  
Contact Information
Name (Last, First M.I.):  
Street Address:  
State (if in U.S.):  
ZIP Code or Mail Code:  
Phone Number (XXX) XXX-XXXX:  
FAX Number (XXX) XXX-XXXX:  
E-Mail Address:  
Credit Card Information
Type of Credit Card:  
Name on Credit Card:  
Credit Card Number:  
Expiration Date (e.g., 02/01):  
       (Dates/number of nights/deposit/full payment, etc)
Additional Comments

Finished?:     Choose "Yes" when done.  (This field has been placed here to prevent you from submitting the form before you are ready by accidentally hitting the "ENTER" key.)