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AISB-2004 University Accommodation Booking

University of Leeds, Leeds LS2 9JT, UK
Web: www.leeds.ac.uk/aisb Email: icsrim@leeds.ac.uk

A limited number of basic on-campus accommodations (single room only) are available for
AISB'04 participants, on a first come first serve basis.

  1. Please complete, sign and return this form by fax to Dr Kia Ng.
    FAX: +44 113 343 5468 (International) FAX: 0113 343 5468 (UK)
  2. Please also email a copy of this form without payment details to icsrim@leeds.ac.uk.
    All booking will be confirm by email. Please do NOT email your credit card details!
Family Name (Surname)
.
Name
.
Title (e.g. Ms,Mrs,Mr,Dr,Prof,...)
.
Name of Institution/Company/...
.
Address
.
ZIP-Code/Postal-Code & City
.
Country
.
Telephone
.
Fax
.
Email
.
Web
.

ROOM TARIFF

PLEASE TICK TARIFF (single room only)
per night
.
Standard room (shared toilet)
£36.00 GBP
.
En suite room
£46.00 GBP
Note: Cancellation one calendar months before the commencement of the convention,
a shortfall charge of £10 per person per night booked will be made. Non-refundable after that.

PAYMENT OPTIONS - PLEASE TICK PREFERRED METHOD OF PAYMENT
.
BY CHEQUE (Only for UK) - Please make your cheque payable to
UNIVERSITY OF LEEDS
.

BY CREDIT OR DEBIT CARD. We are unable to accept American Express Cards.
.
VISA
.
MASTERCARD

Please complete the details below using BLOCK CAPITALS
Name and Initials (as appear on the card)
.
Arrival date (DD/MM/YY) .
Estimated time of arrival (HH:MM) .
Number of nights .
Departual date (DD/MM/YY) .
Card Holder’s Statement Address
.
House number
.
Address
.
Postal Code / Zip Code
.
Country
.
Security Number (last 3 digits number printed on the signature panel on the back of the card)
.
Day Time Telephone Number
.
Card Number
                               
Valid from
.
Valid to (Expiry/End Date)
.
Please debit my account to the sum of
£
Card Issue No (Debit Cards Only)
.
Card Holder’s signature
.
Date (dd/mm/yy)
.

Please FAX your complete booking form to
Dr Kia Ng, FAX: +44 113 343 5468

……………………………………………………………………………………………………
OFFICIAL USE ONLY

Ref Num
  
Authorisation Number
  

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