PERSONAL INFORMATION Important!! Please furnish full name Title Name: Mr. Miss Mrs First Name: Last Name: Important !! Pls furnish complete e-mail address so that our reply could reach you E-mail Address : (Correspondence E-mail address) E-mail Address : (Second e-mail address , if any) Telephone NO. : Correspondence Address : Country : Nationality : BOOKING DETAILS Types of Package (Bangkok) : - - - - - - - - - - Select Package - - - - - - - - - - Special Last Minute Booking Offer Bangkok Special Package Bangkok Special Rates Value Package The VIP Package - - - - - - - - - - Select Hotels - - - - - - - - - - The Imperial Impala Hotel The Imperial Queen's Park Hotel The Imperial Tara Hotel Combined Package Only - - - - - - - - - - - - - - - - Please Select - - - - - - - - - - - - - - - - Imperial Queen's Park Bangkok & Imperial Samui Imeprial Tara Bangkok & Imperial Boat House Samui Types of bed : - - - Please Select - - - Single Twin Double Triple Number of rooms required : 0 1 2 3 4 5 6 Number of person (adult) : Number of children (if any) : Age of children : Date of check in: <%a=1 for a=1 to 31%> selected <%end if%>><%=a%> <% next%> selected <%end if%>>January selected <%end if%>>February selected <%end if%>>March selected <%end if%>>April selected <%end if%>>May selected <%end if%>>June selected <%end if%>>July selected <%end if%>>August selected <%end if%>>September selected <%end if%>>October selected <%end if%>>November selected <%end if%>>December 2004 2005 Date of check out : <%a=1 for a=1 to 31%> selected <%end if%>><%=a%> <% next%> selected <%end if%>>January selected <%end if%>>February selected <%end if%>>March selected <%end if%>>April selected <%end if%>>May selected <%end if%>>June selected <%end if%>>July selected <%end if%>>August selected <%end if%>>September selected <%end if%>>October selected <%end if%>>November selected <%end if%>>December 2004 2005 Indicate here if more than 1 type of rooms are required Please also furnish names of the guest for the additional rooms Indicate here for any special request (bed types preferred, connecting room, etc.) Preferred payment method : Pls select By Visa Card By Master Card By JCB Card FLIGHT DETAILS Arrival flight name & number required : (i.e. TG999) Arrival Date : <%a=1 for a=1 to 31%> selected <%end if%>><%=a%> <% next%> selected <%end if%>>January selected <%end if%>>February selected <%end if%>>March selected <%end if%>>April selected <%end if%>>May selected <%end if%>>June selected <%end if%>>July selected <%end if%>>August selected <%end if%>>September selected <%end if%>>October selected <%end if%>>November selected <%end if%>>December 2004 2005 Arrival Time : : A.M. P.M. (i.e. 5:30 p.m.) Departure flight name & number required : (i.e. TG999) Departure Date : <%a=1 for a=1 to 31%> selected <%end if%>><%=a%> <% next%> selected <%end if%>>January selected <%end if%>>February selected <%end if%>>March selected <%end if%>>April selected <%end if%>>May selected <%end if%>>June selected <%end if%>>July selected <%end if%>>August selected <%end if%>>September selected <%end if%>>October selected <%end if%>>November selected <%end if%>>December 2004 2005 Departure Time : : A.M. P.M. (i.e. 5:30 p.m.) Please contact us if you encounter any difficulties sending your booking details through this form.