Reservation Form

Name *

First

Last
Phone Number *

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Email *
Gender
 Male 
 Female 
Are you local (with MyKad) or foreigner? *
 Local (with MyKad) 
 Foreigner 
 Both local (with MyKad) & Foreigner 
Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Your Preferences

Kindly indicate your preferences as shown below.
Preferred Check In Date *

MM
/
DD
/
YYYY
Preferred Check Out Date *

MM
/
DD
/
YYYY
No. of Adults *
 1 Adult 
 2 Adults 
 3 Adults 
 4 Adults 
 5 Adults 
 6 Adults 
If more than 6 pax, please indicate accordingly.
No. of Children (3-11 yrs old)
 1 Child 
 2 Children 
 3 Children 
 4 Children 
If more than 4 pax, please indicate accordingly.
Preferred Accommodation Type
 'A' Chalets
 House Boat 
 Dormitory (Min. 12 pax) 
Promotional Code (if any)
Where was your last point of departure?
If other point of departure, please indicate.
Do you require any assistance on transportation?
 Yes. Please contact me. 
 No, thanks. 
I prefer to be contacted on...
 Email 
 Mobile / Phone 
 Mobile - SMS 
Any additional remarks
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Feedback & enquiries

Office

Belum Eco-Resort Sdn.Bhd.
(Company Reg. 589609-V)
25, Hala Rasi Jaya 7, Taman Rasi Jaya,
31450 Menglembu, Perak, Malaysia.

TEL/FAX+605 281 0834 / 281 1288