

| Single Occupancy: | $119.00 |
| Double Occupancy: | $119.00 |
| Triple Occupancy: | $135.00 |
| Quadruple Occupancy: | $150.00 |


| Name: |
| Organization or Affiliation: |
| Organization Address: |
| Organization Telephone: |
| City: | State: | Zip: |
| Country: | FAX: |
| Room type desired: |
| ____ | King bed | ____ | Two double beds |
| ____ | Non-smoking room | ____ | Smoking room |
| Arrival: | Departure: |
| I have the following special needs: |
| To guarantee with credit card: (please complete the following information) |
| Visa | Master Card | Amex | Diners | CarteBlanche | (Circle one) |
| Card Number: |
| Expiration date: |
| Print Name as shown on credit card: |
| Signature: |