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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: _______________