Customer Information

Customer Information: Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

		First Name *		Last Name *

		Street Address

		City		State		Zip Code

		E-mail Address *

		Contact Phone		How do you wish to be contacted?

How did you hear about us?

Yellow Pages	Internet
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HOLLYWOOD MOTEL

966 U.S. Highway 1
Avenel, NJ 07001

T: 732-634-3212
F: 732-634-5428
satish57@optonline.net

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