Accommodation form JHTA 2011

Please return this form dated and signed to:
AIM France - JHTA 2011
52, Rue Bichat - 75010 PARIS - France
Phone: +33 (0)1 40 78 38 00 - Fax: +33 (0)1 40 78 38 10
E-mail: [email protected]
Web: www.sfhta.org
ACCOMMODATION FORM
PARTICIPANT DETAILS
Mrs
Miss
Mr
Prof.
FAMILLY NAME
FIRST NAME
In capital letters
in capital letters
Dr
ADDRESS
ZIP CODE
CITY
PHONE
FAX
COUNTRY
E-MAIL
VAT NUMBER
HOTELS
LIST
You can make hotel reservation on line www.sfhta.org or download and print this form to be returned by regular mail or
by fax before November 14, 2011 to the Congress Secretariat dully filled in, dated and signed. Rates include taxes and
breakfasts. For further information about the hotels (access, description…) visit the web site www.sfhta.org.
H01
H02
H03
H04
H05
H06
SELECT
A
Hotel
Méridien Etoile - 4****
Concorde La Fayette - 4****
Balmoral - 3***
Fertel Maillot - 3***
Magellan - 3***
Elysée Etoile - 2**
Single room
219 €
220 €
180 €
145 €
140 €
120 €
Double room
239 €
235 €
200 €
170 €
160 €
145 €
HOTEL
Please choose the hotels references in preference order, and precise the type of room and total amount of your stay.
Choice 1
Hotel selected
Hotel : H ______________
Category
Single – Double
Total amount due
________________ €
Choice 2
Hotel : H ______________
Single – Double
________________ €
Choice 3
Hotel : H ______________
Single – Double
________________ €
Accommodation requests MUST BE ACCOMPANIED BY THE PAYMENT OF THE WHOLE STAY.
Arrival date: _________________ Departure date: _________________ Number of nights: __________________
Comments / specific enquiries: _____________________________________________________________________
Please report your name :
Please return this form dated and signed to:
AIM France- JHTA 2011
52, Rue Bichat - 75010 PARIS - France
Phone: +33 (0)1 40 78 38 00 - Fax: +33 (0)1 40 78 38 10
E-mail: [email protected]
Web: www.sfhta.org
CANCELLATION
ACCOMMODATION FORM
POLICY
Cancellation of registration must be notified to the Congress Secretariat in writing (by regular mail, or fax) according to
the following conditions:
Cancellation on / before November 14, 2011: refund of 50% of the registration fees.
 After November 14, 2011: no refund.
MEANS
OF
PAYMENT
Please indicate which of the following means of payment you intend to use:
By bank transfer (*)
(*) Clearly state « JHTA 2011 » and name of the participant
Please enclose receipt of bank transfer and registration form dully filled in.
Payment must be made to AIM FRANCE - JHTA 2011
Account n°: 1202529R002 - Key: 65 - Bank code: 40978 - Counter code: 00071
IBAN: FR87 4097 8000 7112 0252 9R00 265 - BIC: BSPFFRPPXXX
Banque Palatine - 17-19, Place de Catalogne - 75014 PARIS - France
By credit card, specify:
Visa
Eurocard / Mastercard
I authorize AIM FRANCE to debit the sum of
Card Number:
Euros on my credit card.
Security Code (**):
Expiration Date:
Card holder name:
Card holder address:
Card holder phone number:
Date:
Signature of holder:
(**) Note the last 3 figures of the number representing on the frame signature of your card.
Date:
Signature of participant:
Stamp