HOTEL RESERVATION FORM Housing Deadline: Friday, January 30, 2015  Be sure to make your reservations early as room requests are taken on a first‐come, first‐served basis.  The hotel cannot process reservation forms so do not send directly to hotel. All reservation requests must originate through ADA’s official Housing Company, CMR, to guarantee our negotiated group rate.  If you require 10 or more rooms or would like to reserve a suite, please contact ADA Housing for information.  ADA Housing will e‐mail or fax a confirmation of your reservation within 72 hours of receipt of your form.  For accurate and easy housing you may visit http://professional.diabetes.org/pg15 and reserve your room online. FAX: (415) 216‐2540 MAIL: ADA PG Housing c/o CMR 33 New Montgomery, Suite 1100 San Francisco, CA 94105 QUESTIONS: Phone: (Mon‐Fri, 9:00am‐9:00pm ET) (866) 291‐9696 (Toll Free US & Canada) (415) 268‐2089 (International) E‐mail: [email protected] I. CONTACT INFORMATION (please type or print clearly) First Name:___________________________ Middle Initial:_____ Last Name:____________________________________________ Company/Institution:__________________________________________________________________________________________ Street Address:_______________________________________________________________________________________________ City:_______________________ State/Province:_______ Zip/Postal Code:_______________ Country:________________________ Phone:______________________________________________ Fax:____________________________________________________ E‐mail:_____________________________________________________________________________________________________ Please send a copy of the confirmation to: Additional E‐mail:_____________________________________________________ II. HOTEL INFORMATION Crowne Plaza Times Square Manhattan – 1605 Broadway, New York, NY 10019 $189‐Single/Double/Triple/Quad (Rates do not include the state, city, and occupancy tax currently at 14.75% + $3.50 per room, per night) Room Type/Occupancy – (subject to hotel’s availability) Single (1 person/1 bed) Double (2 people/1 bed) Double/Double (2 people/2 beds) Triple (3 people/2 beds) Quad (4 people/2 beds) Non‐Smoking Smoking Hotel Frequent Guest # _________________ Request handicapped accessible room (please attach a separate sheet to indicate specific needs) First Name Last Name Primary Occupant: Arrival Date Departure Date (Month/Day/Year) (Month/Day/Year) / /2015 / /2015 Share With: / /2015 / /2015 Share With: / /2015 / /2015 Share With: / /2015 / /2015 III. PAYMENT INFORMATION AND TERMS AND CONDITIONS All reservations must be guaranteed by a major credit card or by a check deposit for one night’s room and tax drawn on a U.S. bank, in U.S. dollars, made payable to CMR/ADA Housing. Check/Money Order #________ Visa MasterCard Discover American Express Diners Club Credit Card Number:_____________________________________________ Exp. Date (MM/YY): ______ / ______ Name as it appears on card:_________________________________ Signature:___________________________________________ ADA reserves the right to accept, reject or condition acceptance of any registrant, in ADA’s sole discretion, at anytime. ADA is not responsible for any lost items or any damages, including without limitation any personal or bodily injury that may occur on the premises of the meeting. IV. CHANGES OR CANCELLATIONS  After January 30, 2015, ADA Housing will continue to process reservations and changes subject to hotel availability.  Reservations must be cancelled at least 24 hours prior to your scheduled arrival to avoid penalty charges. If you do not cancel your reservation in time or fail to check‐in on the scheduled date of arrival your credit card will be charged in the amount of one night’s room and tax or your check deposit will be forfeited. Your reservation will also be cancelled for the remainder of the stay.