REGISTRATION FORM - Ortra
REGISTRATION FORM - Ortra
REGISTRATION FORM - Ortra
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>REGISTRATION</strong> <strong>FORM</strong><br />
Please complete this form in clear CAPITAL LETTERS and return to:<br />
<strong>Ortra</strong> Ltd. P. O. Box 9352, Tel Aviv 61092, Israel Fax: +972-3-6384455 Email: iwaenc@ortra.com<br />
Title: ¨ Prof. ¨ Dr. ¨ Mr. ¨ Mrs. ¨ Ms. ¨ Other<br />
Surname: ________________________________ First Name: _____________________________<br />
Affiliation: ________________________________________________________________________<br />
Address: ¨ Institution ¨ Home _______________________________________________________<br />
City:__________________________________________ State: _____________________________<br />
Country: ______________________________________ Zip/Code: __________________________<br />
Tel: ___________________ Fax: __________________ E-Mail: ____________________________<br />
Accompanying Persons:<br />
Surname: ________________________________ First Name: _____________________________<br />
Surname: ________________________________ First Name: _____________________________<br />
Registration fee:<br />
Type<br />
Early Registration<br />
Payment till July 15 th , 2010<br />
Late Registration<br />
Payment from July 16 th , 2010<br />
Participant ¨ 590 USD ¨ 690 USD<br />
Student ¨ 390 USD ¨ 450 USD<br />
Accompanying Person<br />
¨ 150 USD<br />
Payment:<br />
Attached is payment in the amount of US $ _________________________<br />
made out to <strong>Ortra</strong> Ltd. by:<br />
¨ Bank Draft # ____________________________________________________________________<br />
¨ Bank transfer to account # 142-472330, Bank Hapoalim (swift code poalilit), Branch 780,<br />
Itzhak Sade St., Tel-Aviv, Israel. IBAN- IL58-0127-8000-0000-0472-330 . Copy of bank<br />
transfer document enclosed.<br />
¨ Please charge my ¨ Mastercard/ Eurocard ¨ Visa ¨ American Express ¨ Diners<br />
Card # ________________________________________Expiry date ______________________<br />
Credit card owner: _______________________________________________________________<br />
3 digits in the back of the card: _______________________ _____________________________<br />
Signature __________________________________________ Date ________________________
TOURIST SERVICES <strong>FORM</strong><br />
Please complete this form in clear CAPITAL LETTERS and return to:<br />
<strong>Ortra</strong> Ltd. P. O. Box 9352, Tel Aviv 61092, Israel Fax: +972-3-6384455 Email: iwaenc@ortra.com<br />
Title: ¨ Prof. ¨ Dr. ¨ Mr. ¨ Mrs. ¨ Ms. ¨ Other<br />
Surname: ___________________________________ First Name: __________________________________<br />
Affiliation: ________________________________________________________________________________<br />
Address: ¨ Institution ¨ Home ________________________________________________________________<br />
__________________________________________________ City: __________________________________<br />
Country: __________________________________________ Zip/Code: ______________________________<br />
Tel: _____________________Fax: ____________________ E-mail: ________________________________<br />
Accompanying Persons:<br />
Surname: ___________________________________ First Name: __________________________________<br />
Surname: ___________________________________ First Name: __________________________________<br />
Please make the following reservations:<br />
A. AIRPORT TRANSFERS<br />
¨ I require private transfer from Ben Gurion International Airport to my hotel at US$85 per car.<br />
¨ I am scheduled to arrive on: Date ____________ Flight _________From ____________Time____________<br />
¨ I shall inform you of flight details at a later date, but no later than one week prior to arrival.<br />
B. DAILY ACCOMMODATION (Please mark X)<br />
Hotel Single Room- Per Night Double Room- Per Night<br />
Sheraton Tel Aviv Hotels<br />
(Workshop Venue) Standard Room<br />
¨ $ 245 ¨ $ 280<br />
Sheraton Tel Aviv Hotel<br />
(Workshop Venue) Club Room<br />
¨ $ 313 ¨ $ 358<br />
Leonardo Basel Tel Aviv ¨ $ 155 ¨ $ 165<br />
The City Hotel, Tel Aviv ¨ $ 140 ¨ $ 150<br />
Dates: From_______________________ To: _______________________Total # of Nights: _______________<br />
C. OPTIONAL TOURS<br />
¨ Evening tour 1: Bauhaus – The "White City" (US$45)<br />
¨ Evening tour 2: Romantic Tel Aviv (US$45)<br />
¨Post Tour I - Dead Sea & Massada 1 Day Tour (US$ 90)<br />
September 3, 2010<br />
D. PAYMENT<br />
Attached is payment in the amount of US $ _____________________made out to <strong>Ortra</strong> Ltd. by:<br />
Bank Draft # ____________________________________________________________________________<br />
Bank transfer to account # 142-472330, Bank Hapoalim (swift code poalilit),<br />
Branch 780, Itzhak Sade St., Tel-Aviv, Israel. Copy of bank transfer document enclosed.<br />
Please charge my ¨ Mastercard/Eurocard ¨ Visa ¨ American Express ¨ Diners<br />
Card # ____________________________________________ Expiry date __________________________<br />
3 digits in the back of the card: ______________________________________________________<br />
Credit card owner: _______________________________________________________________________<br />
Signature ________________________________________________ Date ____________________________
Change language