Civility: Mr Mrs Miss

Surname*:

First name*:

Company:

Address*:

Postcode*:

Town*:

Country*: Afghanistan Aland Island Albania Algeria Andorra Angola Anguilla Island Antarctic Antigua and Barbuda Argentina Armenia Aruba Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Congo (The Democratic Republic of the) Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lituania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Salvador Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Western Sahara Yemen Zambia Zimbabwe

Telephone*:

E-mail*:

Type of room/suite:*: Standard Duplex

Arrival date*: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2011 2012 2013 2014 2015

Departure date*: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2011 2012 2013 2014 2015

Planned arrival time: h

Number of nights*:

Number of adults*:

Number of children*: (up to age 6)

Any information you give is for the use of the Saint-André Group of hotels and residences only. The Saint-André Group of hotels and residences will not pass this information on to any third parties. You are entitled to access, modify, alter or delete any personal data relating to you (article 34 of the French Data Protection act). To do so, write to the Saint-André Group of hotels and residences, 22 rue Jean Louis Barrault 26000 Valence, France.