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)