Workshop on Positron Emission Mammography 1 and 2 July, 2002 Lisbon, Portugal --------------------------------------------------------------------- RESERVATION FORM - HOTEL EDEN --------------------------------------------------------------------- FAMILY NAME: _____________________________________________________ FIRST NAME: _____________________________________________________ INSTITUTION: _____________________________________________________ ADDRESS: _____________________________________________________ _____________________________________________________ PHONE: _____________________________________________________ FACSIMILE: _____________________________________________________ (TYPE AN "X" IN THE SPACES CORRESPONDING TO YOUR CHOICES) Please book me a ___ Studio (97 Euro/day) Date of arrival: 2002/____/___ Date of departure: 2002/____/___ ___Visa ___Eurocard ___Mastercard ___American Express Credit card number: _____________________________________ Credit card name: _____________________________________ Expiry date: ____/___ (e.g. 11/00) Signature: _____________________________________________ --------------------------------------------------------------------- PRINT and send by FAX to HOTEL EDEN Praca dos Restauradores, 24 1250-187 Lisboa, Portugal Fax: +351-21-321-6666 Tel: +351-21-321-6600 ---------------------------------------------------------------------