HOTEL ACCOMMODATION REQUEST FORM

HOTEL ACCOMMODATION REQUEST FORM
FAX COMPLETED FORM TO +39-010-255009*
Email: [email protected]
Symposia O.C.– Piazza Campetto, 2/8, 16123 Genova, Italy | Phone +39-010-255146
PLEASE PRINT
First Name: ____________________________________Last Name_________________________________________________
Accompanying person(s) First Name:____________________________________ Last Name:____________________________
First Name:____________________________________ Last Name :________________________________________________
Company/Organization: ___________________________________________________________________________________
Preferred Mailing Address:__________________________________________________________________________________
City: ________________________________ State/Province: ______________________ Zip/Postal Code: _________________
Country: _____________________________ Telephone: (______)__________________ Fax: (______)____________________
Email: __________________________________________________________________ ETI-AVS Faculty member  Yes  No
HOTEL ACCOMMODATION PREFERRED CHOICE
ETI-AVS has secured hotel rooms for our attendees at the following hotels. Please note rates and indicate your first and second choices by completing
the form below.
Please note that the accommodation confirmation shall be sent upon actual availability at the time your application is received, thus the Organizer cannot be
held liable in any way if the accommodation requested is not available when your request is received. If your preferred choice is not available, another
option shall be proposed to you and not confirmed before your approval. Please note that your CREDIT CARD DETAILS are necessary to confirm the
reservation. TOTAL PREPAYMENT REQUIRED! PLEASE CHOOSE IF YOU WISH TO PAY VIA BANK TRANSFER OR CREDIT CARD. Prices are quoted per day in €UR and
include BED/BREAKFAST, GOVERNMENT and TOURIST TAXES. Submitting this signed form to the Organizer is confirmation that the Participant understands these
details and accepts and approves of them in their entirely.
PLEASE COMPLETE AND RETURN ALL PAGES
Hotel Room Request
ROOM TYPE REQUESTED: SINGLE*
First choice _______________________
DOUBLE *
TWIN*
Second choice _________________________
Number of Rooms _________________
Check in date:_______________________ Check out date: _________________ Total number of nights: __________________
Please list any special requests for room types below: (example: two beds, smoking, non smoking, child bed, etc.). Requests will be
submitted to the hotel and are not guaranteed.
___________________________________________________________________________________________________
* For US citizens only:
Please send your completed hotel accommodation request form to
Fax Number +1-602-266-6018 or Email: [email protected]
ISES ▪ 1928 E. Highland Ave F104-605 ▪ Phoenix ▪ Arizona 85016 ▪ USA Phone: 1-602-650-133499
ETI Secretariat - Symposia O.C. srl – Palazzo del Melograno, Piazza Campetto 2/8, 16123 Genova (Italy)
MEETING VENUE
La Bagnaia Conference Center
S.S. 223 Siena-Grosseto km 56
53016 Località Bagnaia SIENA, Italy
HOTELS WITH SPECIAL ETI-AVS ROOM RATES
La Bagnaia Resort (*****)
S.S. 223 Siena-Grosseto km 56
53016 Località Bagnaia SIENA, Italy
Room rates
DUS (Double Used as Single) € 220,00
DBL (Double) € 270,00
Borgo di Filetta (****)
S.S. 223 Siena-Grosseto km 56
53016 Località Bagnaia SIENA, Italy
Room rates
DUS (Double Used as Single) € 145,00
DBL (Double) € 195,00
Locanda del Ponte (****)
Loc. Ponte a Macereto S.S.223
53015 Monticiano (SI) Italy
Room rates
DUS (Double Used as Single) € 80,00
DBL (Double) € 105,00
ROOM RATES
HOTEL
La Bagnaia Resort
Borgo di Filetta
Locanda del Ponte
CATEGORY
5*
4*
4*
SGL/DSU
220,- €
DOUBLE/TWIN
270,- €
145,- €
195,- €
80,- €
105,- €
ENDOVASCULAR THERAPY INTERNATIONAL - ADRIATIC VASCULAR SUMMIT
ACCOMMODATION PAYMENT FORM
 PAYMENT BY CREDIT CARD
 PAYMENT VIA BANK TRANSFER – CREDIT CARD AS A GUARANTEE (bank account details will be sent via email)
Full reservation prepayment is required at the time of the hotel booking. Hotel reservation requests received after July 31, 2012 cannot be
guaranteed. Only reservations accompanied by payment will be processed. No refund is possible in the case of cancellation. Hotel
confirmations will be emailed.
Credit Card Type:  VISA  MasterCard  AMEX
 Diners Club Card Number: _________________________________
Card Expiration Date (mo/yr): ________/_________ Security Code: _____________
P rint Full Name on Credit Card: ________________________________________________________________________________
Card Billing Address: ________________________________________________________________________________________
City: ________________________________________ State: __________________________ Zip/Postal: __________________
Country:____________________________________________
Signature: _________________________________________________________________________________________________
ETI Secretariat - Symposia O.C. srl – Palazzo del Melograno, Piazza Campetto 2/8, 16123 Genova (Italy)