<p>HOTEL RESERVATION FORM Strategies for Private Sector Engagement and Public Private Partnership in Health The Faculty of Economics, Chulalongkorn University 29 May – 05 June, 2011 DELEGATE INFORMATION (Please complete all fields in CAPITAL letters)  Mr  Mrs  Ms Confirmation# (for Hotel fill in only):……………... Family name:…………………………………………………... First Name:……………………...... Company:.………………………………………………………………………………………………………………….. Company Address:………………………………………………………………………………………………………… Postcode:…………...... City:.………………………… Country:…..………………………………………… Fax:………………………………………………………....….. Email:…………………..…………………………… Arrival Date:………...... From:……...... …...... Flight No:.…………………………………………… Departure Date:.………...... To:...... ………….... Flight No:……………………………………………. Special Requests:  Non Smoking  Smoking ACCOMMODATION * Please book on my behalf in The Montien Hotel, Bangkok Address: 54 Surawongse Road, Bangkok 10500, Thailand Tel: 66 (0) 2233 7060-9 Fax: 66 (0) 2236 5218-9 website: www.montien.com/bangkok Room Type Room Rate/ night* / Incl ABF Superior room (32 sqm)  Single Baht 2,200.-net  Twin/Double Baht 2,600.-net The quoted rates are net inclusive of 10% service charge, 7% applicable government tax In order to guarantee your reservation as shown above, please indicate your Credit card no. below :</p><p>Expiry date : (mm/yy)</p><p>Cardholder’s Name (as it appears on the credit card): ______Type: □ Visa / □ Master Card / □ American Express Date:______Signature:______*Note : 1) The preferential rates are net inclusive of 10% Service Charge & 7% VAT per room per night. Buffet breakfast included. 2) The hotel bill must be settled on an individual basis upon checking out of the hotel. 3) One night room rate will be charged in the event of NO-SHOW or notification of cancellation less than 7 days prior to arrival. 4) All reservations will be held until 16:00 hrs., unless guaranteed by credit card and flight details or expected time of arrival is provided.</p><p>AIRPORT TRANSFER Yes: Please arrange airport transfer From airport to hotel price at Baht 1,400.-net per car Round trip transfer price at Baht 2,800.-net per car </p><p>For reservation please contact Reservations Department - Email: [email protected], Fax: (662) 236-5218</p><p>54 Surawongse Road, Bangkok 10500, Thailand. Phone: (662) 233-7060-9, 234-8060-79 Fax: (662) 236-5218-9</p>