MUST FAX
OR MAIL THIS FORM TO COMPLETE BOOKING
ECRYPT NoE CRYPTANALYSIS SUMMER SCHOOL
Pythagorion,
Please complete the sections below. Please print clearly and in CAPITALS.
To register, either:
- Fax the completed booking form with credit card information to +32 16 32 19 69.
- Send the completed booking form with payment information to:
Pela Noe
ESAT/SCD-COSIC
Kasteelpark Arenberg 10
3001 Heverlee
1.
PERSONAL
INFORMATION
Title/First Name/Last Name : __________________________________________________
Company/Organisation: ______________________________________________________
Mailing Address: ____________________________________________________________
Phone : __________________________ Fax : ________________________
E-Mail : ________________________________________
2.
TYPE OF ROOM
O Single room, breakfast only (€48 per night) O Single room, half board (€60 per night)
O Double room, breakfast only (€60 per night) O Double room, half board (€80 per night)
If you are taking a double room, please indicate the name of your roommate here:
_________________________ Your roommate does NOT have to send us a second booking form.
3.
DATES
Arrival Date:_______________ Departure Date: _______________
Total number of nights at the hotel: _______________
4.
PAYMENT
Payment must be done directly to the hotel when in
O Use the following credit card information
O Mastercard O Visa
Card Number: __________________________ Expiry Date : ________________________
Card Holders Name: __________________ Card Holder’s signature: