Family name: _________________________________ Mr. O Mrs. O First Name: _____________________________ Initials: ______________ Title/Function: Prof. ( ) Dr. ( ) Engineer ( ) Ph.D./MSc.student ( ), Other ( ) Organisation: ___________________________________________________________ Department: _____________________________________________________________ Address: ________________________________________________________________ Postal Code: _________________________ City: ___________________________ State/Province: ______________________ Country: ________________________ Tel.: + _____________________________ Fax: + _________________________ Email: __________________________________________________________________ Hotel accommodation needed? Yes/No If yes, please indicate the period and the choice of the hotel. From March ..., 2004 to March ..., 2004, hotel choice _______, room (Single/Double):________. 1. Hotel Leeuwenburg *** (http://www.leeuwenbrug.nl/) Single room: 67.50 euros per night; Double room: 82 euros per night. (incl. breakfast, excl. tourisme tax of 2 euros) It is approx. 10 minutes from station Delft, and at 20 minutes walking distance to the Mekelweg 4 (workshop venue). 2. Dutch hotel Hotel *** (http://www.dutchhoteldelft.nl/) Single room: 94 euros per night; Double room: 109 euros per night. (incl. breakfastand tourisme tax) It is approx. 15 minutes from station Delft, and at 10 minutes walking distance to the Mekelweg 4 (workshop venue). I will be accompanied by the following person(s); when children mention their age Mrs./Mr.:________________________________________________________________ P.S. a limited number of hotel rooms is available (double room, shared with another participant), you can ask the organisers about the availablitiy by email.
Workshop receptions and dinner (the workshop, receptions and dinner are free of charge)O Reception at March 15 (evening) Yes/No O Reception at March 16 (evening) Yes/No O Reception at March 17 (evening) Yes/No O Dinner at March 18 (evening) Yes/No Signature:___________________ Date:______________________
This form should be faxed or e-mailed to as soon as possible:
Organizers SWI 2004
Faculty of Electronics, Mathematics and Informatics
Mekelweg 4, 2628 CD Delft, The Netherlands
Fax: + 31 15 2787245 or 2787295