HOTEL ACCOMODATION FORM

Surname__________________________ Name____________________________

Address__________________________ Nr.______________________________

ZipCode________________City_____________________Country________________

Institute/Hospital/University________________________________________________

Tel. Home_________________________ Tel. _____________________________

Inst./Hosp/Univ.____________________ Tel. mobile_________________________

Fax_______________________________

Would like to book: __ single room __ double room

Name of accompainying person _____________________________________________

__ Transfer service

Airport – Grand Hotel Chia Laguna __ June 18th

Grand Hotel Chia Laguna – Airport __ June 24^th

Social diner (for the participants who do not wish to buy the hotel package)

__ June 23

Arrival date____________ flight nr.________________________ hour _____________

Departure date __________ flight nr.________________________ hour _____________

METHODS OF PAYMENT

Credit card: __ Eurocard/Mastercard __ VISA

Credit card details: Please print names and numbers clearly.

Credit card number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Credit card owner ________________________________Date of Birth: .......................

Expiry date: __ __ / __ __ __ __ Signature:……………………………………………

All payments by credit card must be sent by fax or post

I am sending __ bank transfer or __ eurocheque n.__________________________ of

Lit.____________________ Bank________________________________addressed to Centromed

For nr ________ persons, whose deposit above confirmation of the hotel booking

Centromed will address the invoice to:______________________________________________________________________

Address_________________________________________________________________

Zip code_____________________________City_________________________________

Country_________________________________________________________________

Fiscal Code – VAT:________________________________________________________

This form is valid only if accompanied by the total amount of the services requested.

In accordance with rule 675/96 of the Italian law, the use of the above data is allowed.

Date Signature: ........................................................................

To send to:

Travel Agency Centromed sas–

Via XXIX Novembre 22 – 09123 Cagliari Tel. 070 656231 Fax. 070 672517

E-mail: mfserrau@tiscalinet.it

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Last updated on:  10. May 2000 by A.Bischoff