39th ISICEMInternational Symposium on Intensive Care and Emergency MedicineSQUARE - BRUSSELS MEETING CENTER - MARCH 19-22, 2019

Booking

PERSONAL INFORMATION

Gender Mr. Miss Mrs.
Surname / Family name
First name

Company Details

Company / Institution
Address
Post Code
Town
Country
Phone number
Fax
Email

Billing address

tick if same as above
Name
Address
Post Code
Town
Country
VAT
Phone number
Fax
Email

HOTEL BOOKING INFORMATION

HotelThe Dominican****
Arrival date
Departure date
Room type / occupancy Single Double occupancy
Amount
Including breakfast and city taxes
0,00 €

ADDITIONAL INFO

Type room
Late arrival
(rooms are kept secured even if case of late arrival)

ACCOMPANYING PERSON SHARING THE SAME ROOM

Family name
First name

PAYMENT METHOD

By bank transfer - Please email me the invoice. The amount will be wired on due time
By visa or Master card - Please email me the invoice and a payment’s secured web link from Europabank
By American Express - Please charge my credit card and email me the invoice and hotel voucher

COMMENTS

Travex Congress
Parvis de la Trinité 8, 1050 Bruxelles

VAT : BE 0414.435.171 –IATA : 0820007.6 – Lic. A1078

Mr. Denis Cochez
Phone : ++32.2.533.20.44
Fax : ++32.2.537.75.88
d.cochez@travex-travel.be