Travel Insurance Request Form

Important Information Travel Insurance Costs – CA$ 8.50 per day – refundable only if cancelled 48 hours prior to start date. Administration Fees – CA$ 25.00 per request – non-refundable. Payment Terms: MKA Hotels require a credit card number to charge the appropriate costs/fees. Approx. Exchange rate: 1 CAD = 1.15 USD

Delegate Information
Dr. Mr. Mrs. Ms.	Family Name	First Name
City	E-mail
Country	Tel:	Fax:
Date of Birth (mm/dd/yyyy)

Dates of Travel
Departure from Home Country (mm/dd/yyyy)	Return to Home Country (mm/dd/yyyy)

Credit Card Details
YES, I, the cardholder named below, authorize MKA to charge the following card for administration and travel insurance fees.
Visa MasterCard #	Expiry Date:
Cardholder:	CVV/CVC Code:
The credit card provided WILL be charged for all fees and travel insurance costs.	3-digit security code on back of card

Acceptance of Terms – The following MUST be accepted (“ticked”) to make a booking.
YES, I, the delegate named above, have read and accept the terms and conditions as outlined above
Box must be “ticked” to make a booking.)
YES, I agree that by completing this form and submitting it electronically to hotels@mkaconf.com or via fax to 1-613-248-5064, a signature is implied and I am bound by all of the terms, conditions fees and penalties that are outlined above.
(Box must be “ticked” to make a booking.)

Submit completed form via e-mail to hotels@mkaconf.com or via fax to 1-613-248-5064