The XXXIInd World Congress of the International Society of Hematology

Abstract Submission Form

Online Registration

Registration Information
Complete the fields and press the Submit button at the bottom of the page.
Required fields are marked with an asterisk *.

I.Personal Information

Title *	Dr. Mr. Mrs. Ms. Prof. Other

First Name *

Family Name *

Nationality*

Institute / Organization*

Position*

Department*

Address line 1*

Adress line 2

City

State

Postcode *

Country *

Telephone (inc. international code) *

FAX

Email *

Accommodation

II. Hotel

Congress Venue

Room Rate

		Single	Twin
Centara Grand	Superior	$175	$185
	Deluxe	$190	$200

Hotel Category

Room Rate

Category A

InterContinental	Single	Twin
	$185	$195

Amari Watergate	Single	Twin
	$150	$160

Category B

Holiday Inn Bangkok	Single	Twin
	$130	$140

Novotel Siam Squares	Single	Twin
	$125	$130

Siam City	Single	Twin
	$125	$135

Imperial Queen's Park	Single	Twin
	$114	$123

Category C

Arnoma	Single	Twin
	$105	$105

Windsor Suites	Single	Twin
	$90	$100

Novotel Lotus	Single	Twin
	$90	$100

Ambassador	Single	Twin
	$79	$86

Royal Benja	Single	Twin
	$70	$75

Imperial Tara	Single	Twin
	$70	$75

The above rates are in US Dollar
* The above rates are Subject to 10% Service charge + 7% Valued added tax.

III. Please mark your second and third choice of hotel

Hotel of second choice:
Hotel of third choice:

Twin/Double Share: if sharing. please indicate the name of the shared person.Deposit are required from one person only in a twin/double share arrangement.

I am sharing a room with :

Check-In Date
Check-Out Date
Number of night(s)
Number of room(s)
Payment Method :	One night only All the room cost
Total:	US$

IV. Mode of Payment

Credit card

I authorize the Organizing Committee of ISH 2008 to charge the total amount indicated above to the following credit card :

Master card VISA

Please note that only VISA Card and Master Card are accepted. The card number, the cardholder's name, the expiry date and the security code on card (which is the last three or four digit number appearing on certain card) on the signature panel must be indicated in the Registration Form.

V. Credit Card Holder

Please type or write in block letters
Delegate: Dr. Mr. Mrs. Ms. Prof. Other

**First name :		**Last name :
Address
*E-mail: