HOUSING  REGISTRATION  FORM

(Submit this to The Hotel Providence)

The Jungian Society for Scholarly Studies 2005 Conference 

Due Date: July 1, 2005

NAME (Please Print):        ______________________________________________________

Home Address:               ______________________________________________________

(Include Zip Code)           ______________________________________________________

(Include Postal Code)      ___________________________________Country:____________

Home Telephone:            (          )_______________________________________________

Email Address:                ______________________________________________________

PLEASE!!  Print Clearly!!

Earliest Check-in:  Wednesday, 08/03/05                      Latest Check-out:  Sunday, 08/07/05

     Date Checking In: _______________                            Date Checking Out: _______________

** Name of Co-occupant (Please submit, even if your name appears on your partner’s form):

Please Print:  _______________________________________________________________________

METHOD OF PAYMENT:

VISA / MasterCard    _____________________________________________  Exp: _______________

American Express      _____________________________________________  Exp: _______________

Name on Card          _________________________________________________________________                                                 PLEASE!!  Print Clearly!!

NOTE WELL:  Reservation  must be received by July 1, 2005, by The Hotel Providence.

The Hotel Providence

311 Westminster Street

Providence, RI 02903-3301

Reservations (toll free):  800-861-8990

Reservations (local number):  401-861-8000

FAX:  401-861-8002