First Name:____________________________ Last
Name:__________________________________
Email:____________________________________________________________________________
Company/Organization:______________________________________________________________
Address:__________________________________________________________________________
City:___________________State/Province:________________ Zip/Postal
Code:________________
Country:_______________________ Tel:______________________ Fax:______________________
Arrival Details
: MIT-W3C Discount Room Rate: $130.00 (plus tax) Single/Double.A credit card number is required to process your hotel reservation.
Card Holder:________________________________________________ (Please Print)
Card Number:___________________________________ Exp. Date(Month/Year):_____/_____
Signature:_______________________________________________Date:_________________