Public Health in the 21st Century - Hotel Reservation Form

Check here for the Hotel Registration Form in PDF format (Portable Document Format)
Public Health in the 21st Century:

Behavioral and Social Science Contributions

Atlanta, Georgia May 7-9, 1998
Hotel Registration Form

Complete this reservation form and mail with payment to:	Atlanta Marriott Marquis Hotel
	265 Peachtree Center Avenue
	Atlanta, Georgia 30303
	Ph# 404-521-0000
	Fax# 404-586-6299

Name: ____________________________________________________________
Title:____Dr. ____Mr. ____Mrs. ____Ms

Affiliation: ______________________________________________________

Mailing Address:________________________________________________________________

Work Phone:( )_______________ Home Phone:( )_______________ Fax:( )_______________

E-Mail: _______________________________________

TYPE OF ROOM:
___Single for $96 ___Double for $96
___Smoking ___Nonsmoking

RESERVATIONS MUST BE GUARANTEED BY ONE OF THE FOLLOWING:
___Visa ___Mastercard ___American Express ___Discover ___Diners Club ___Check ___Money Order

Cardholder name:
(as it appears on credit card) ___________________________________________

Amount to be charged: $________ Credit card number: _______________________________________

Expiration date: _____________ Signature (required): ______________________________________

To ensure that you are to enjoy a meaningful conference experience, please indicate any accomodation requirements or special requests that you may have because of a disability

Reservations received after April 1, 1998, or after hotel room block is filled are subject to availability and prevailing rates. Early reservations are strongly recommended. All reservation requests will require a one (1) night's advance deposit that will be refundable only if the reservation is cancelled at least 72 hours prior to arrival date.