2010 Bangkok Rotary Institute

Zones 6B, 7A and 10B
19 - 21 November 2010
The Imperial Queen’s Park Hotel, Bangkok, Thailand

REGISTRATION / HOUSING REQUEST FORM

Convener: RI Director Jackson S. L. Hsieh Institute Chair: PDG. Dr.Saowalak Rattanavich

Pre-Institute Governors-Elect Training Seminar
Pre-Institute District Trainers Training Seminar
Pre-Institute Governors-Nominee Training Seminar
Pre-Institute Golf Fellowship
Pre-Institute Regional Rotary Foundation Seminar / November 17-18, 2010
November 18, 2010
November 18, 2010
November 19, 2010
November 19, 2010 / 8:30-21:30
8:30-17:00
8:30-18:00
7:00-13:30
8:30-13:30
Rotary Institute November 19, 2010 - Afternoon of November 21, 2010

Rotarian: 1. 2. 3. .

Family Name First Name Call Name (Badge)

4. Current Title in Rotary: 5. Major Donor: Yes No

6. Rotary District: 7. Rotary Club: 8. Country:

9. Address:

10. Email: 11. Mobile:

12. Phone: ( ) 13. Fax: ( )

Spouse: 14. 15. 16.

Family Name First Name Call Name (Badge)

17. FOOD PREFERENCE: Rotarian Regular Vegetarian Spouse Regular Vegetarian


18. HOTEL BOOKING: The official hotel will be the Imperial Queen’s Park Hotel. There are two choices of room:

Deluxe: Baht 3,200.-net include Breakfast (Single/Twin Occupancy) – (Approx. US$97) Exchange rate:US$1.00 = Baht 33.00 (Approx.)

Premier: Baht 3,500.-net include Breakfast (Single/Twin Occupancy) – (Approx. US$106) 19. No. of nights required:

(The above rates are net, inclusive of 10% service charge and VAT, currently at 7%)

¾ Hotel check-in time is 1400 hours and check-out is 1200 hours. 20. Airport transfer required? Yes No

21. Arrival date: 22. Arrival time: 23. Flight No.: From:

24. Departure date: 25. Departure time: 26. Flight No.: To:

REGISTRATION FEES & HOTEL DEPOSITS: / No. of Person / Unit Price / Sub-Total
27. Institute (Rotarian) / x / US$150.00 / =
28. Institute (Spouse) / x / US$100.00 / =
29. Governors-Elect Training Seminar (includes Spouse) / x / US$200.00 / =
30. Governors-Nominee Training Seminar (includes Spouse) / x / US$80.00 / =
31. District Trainers Training Seminar (includes Spouse) / x / US$80.00 / =
32. Regional Rotary Foundation Seminar (includes Spouse) / x / US$50.00 / =
33. Golf Fellowship / x / US$80.00 / =
34. Hotel Deposit (US$100/per room) / x / US$100.00 / =
TOTAL / US$

PAYMENT BY:

35. Cash 36. Credit Card: Visa MasterCard

37. Card No.

Expiry Date: /

(month) (year)

Name as it appears on the card: Signature:

Registration and Inquiries:

Please Fax this form to: +662-651-2838 or via Email:
Rotary Institute Website: www.2010bangkokrotaryinstitute.org