1. Healthcare

2015 SUMMER SPONSORED SHORT-TERM HOUSING RESERVATION FORM
TO RESERVE ACCOMMODATIONS, PLEASE DO ONE OF THE FOLLOWING—Conference Services does not take reservations by phone.
Please do not email the form containing credit card information.
•
MAIL the completed housing reservation form with payment to: P. O. Box 400734, Charlottesville, VA 22904-4734.
•
HAND DELIVER the completed housing reservation form with payment to the Conference Services office between the hours of 8AM to 5PM,
Monday through Friday.
• Full Payment must accompany your reservation form in order for it to be processed.
RESERVATION DEADLINES
30 DAYS PRIOR TO ARRIVAL DATE.
ALL FORMS MUST BE RECEIVED BY 5:00 PM ON THE DEADLINE TO AVOID A LATE FEE.
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LATE RESERVATION FEE: A late reservation fee of $50.00 will be assessed to all forms received after the above deadline. We cannot guarantee
requests for accommodations submitted after the deadline; however, we will make every effort to meet your request.
CANCELLATION POLICY: If Conference Services receives written notice of cancellation at least seven days prior to your scheduled arrival date,
you will receive a refund less a $50.00 cancellation fee. Student residents will be charged $50.00 plus one-week’s (7-days) stay in housing for
cancellation requests received less than one week (7 days) before the scheduled arrival date. This includes requests made after check-in.
Personal Information (FILL OUT THIS FORM COMPLETELY. PLEASE TYPE OR WRITE LEGIBLY IN BLUE OR BLACK INK.)
Name:
________________________________
Local Address:
City, State, and Zip
Gender: M
F
Student ID #:
________________________
___________________________________________________________________________________________
E-mail Address: ________________________ Local Phone #: _________________ Permanent Phone #: _______________
Permanent Address:
City, State, and Zip
______________________________________________________________________________________
Handicapped-accessible accommodations required? Y
Are you a UVA student? Y
Roommate request:
N
N
If Yes, please explain on a separate sheet.
Check One: ¨ Undergraduate ¨ Graduate ¨ High School ¨ Other
_____________________________________________________________
All roommate requests must be mutual and designated as such on both/all reservation forms in order to be honored.
Roommates share an apartment but all bedrooms are single occupancy.
Affiliated Group:
McIntire Business Institute (MBI)
Arrival and Departure Information
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•
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There is a Two-Night minimum stay required for all reservations.
The earliest possible arrival date is Wednesday, May 20, 2015. The latest possible departure date is Friday, July 31, 2015.
Check-in is after 2:00 PM on all other scheduled arrival dates. Check-in location will be communicated by e-mail via your registration
confirmation.
All students must vacate their housing by 11:00 am on the day indicated on your reservation form. Keys must be returned to the Conference
Services office in Page House.
The latest possible departure time is 11:00am on Friday, July 31, 2015. You MUST return your keys & vacate your room before the
designated time to avoid additional charges.
Charges & Payments
Charges are based on the number of NIGHTS, charged at $40.00 per night. A late fee of $50.00 must be applied to all reservations received by
Conference Services after the deadline. Checks (made payable to the University of Virginia) are processed immediately.
Dates of stay:
/
/ 15 to
/
/ 15
Total number of nights:
Cost per night:
Housing charges:
Late reservation fee, if applicable:
TOTAL AMOUNT DUE:
X $34.00
$
$50.00
$
Circle Payment Method:
Check
Credit Card
Credit Card Number:
Expiration Date:
By providing my signature, I attest that I have read and understand all of the information above.
Signature:
______________________________
Date:
PO Box 400734, Charlottesville, VA 22904-4734
Web: www.uvaconferenceservices.com Phone: (434) 924-4479
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