Therapeutics 2003

Please tick	Prof. Dr. Mr. Ms.
Name :
Institution :
Address :
Tel :	Fax :	E-mail :

HOTEL ACCOMMODATION INFORMATION

Name of Hotel

1^st Choice:

2^nd Choice:

3^rd Choice:

Preference: Single Double Twin

Requirement

_________(numbers) room

_________(number) night

Check-in (time) _________ Carrier & Flight No. _________ From:
_________ (Place)

Check-out (time) _________ Carrier & Flight No. _________ To:
_________ (Place)