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ICDM '03
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Please mail or fax this form with check or credit card information to:
Holiday Inn, Melbourne Oceanfront
Attn: Reservations Department
2605 North Highway, A1A
Indialantic, FL 32903
USA
Fax: +1-321-773-6132
Phone: 1-800-465-4329 (toll free in US and Canada) or
1-321-777-4100 (from other countries)
Please Print
Name:__________________________________________________________________
Last/Family First Middle Initial
Affiliation:___________________________________________________________
Address:_______________________________________________________________
City:___________State/Province:_________Zip:____________Country:_______
Phone:___________________________________Fax:__________________________
Please indicate the type of room you prefer:
( ) Single (one bed): US$64.00
( ) Double (two beds): US$64.00
( ) Smoking ( ) Non-Smoking
Arrival Date: _______________Time:______________ Flight:_____________________
Departure Date: ________________Time:______________ Flight:__________________
Deposit (one night):
Check: ( )
Credit Card: ( ) MasterCard ( ) Visa ( ) American Express
( ) Diners Club ( ) Discover
Credit Card Number: _______________________________Expiration Date:__________
(Please type or print clearly)
Signature:_____________________________________________ Date: _______________