BANGKOK OFFICE
11th Floor, Modern Town Building
87/104 Sukhumvit Soi 63
Bangkok, 10110
Thailand

Tel: +66 (0) 2 711 6900-12
Fax: +66 (0) 2 381 5852

HUA HIN OFFICE
73/4 Petchkasem Road, Hua Hin
Prachuab Khirikhan, 77110
Thailand

Tel: +66 (0) 3253 6536
Fax: +66 (0) 3251 1154

Reservations

Please fill in the details as required below and click “submit” to send to the Chiva-Som reservation office. You will be contacted shortly.

All fields marked with * are required

Arrival Date *

Departure Date *

RETREAT *

Minimum stay of 3 nights A taste of Chiva-Som      (Chiva-Som Experience) Physical Renewal     Spa Pampering     Minimum stay of 5 nights Art of Detox      (Detox) Eternal Youth       Fitness       Inner Peace      (De-stress) Member's Special Rate       Natural Healing      (Holistic Health) Weight Management       Yoga for Life      (Yoga)

ROOM TYPE *

Ocean View Thai Pavilion Herbal Suite Fragrance Suite Rainforest Suite Golden Bo Suite Leelawadee Suite

PERSONAL INFORMATION *

Guest Name * -DrMrMsMrs		Surname *
Guest Name    -DrMrMsMrs		Surname

(if two people are sharing please provide both names)

Your Home Address *
City		Country AfghanistanAlbaniaAlgeriaAndorraAngolaAntarcticaAntiguaArgentinaArmeniaAustraliaAustriaAzerbaijan BahamasBahrainBangladeshBarbadosBelarus BelgiumBelizeBeninBermudaBhutan BoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundi CambodiaCameroonCanadaCape VerdeCentral African Republic ChadChileChinaColombiaComoros Congo, Democratic RepublicCongo, Republic of theCosta RicaCote d'IvoireCroatia CubaCyprusCzech Republic DenmarkDjiboutiDominicaDominican Republic East TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopia FijiFinlandFrance GabonGambiaGeorgiaGermanyGhana GreeceGreenlandGrenadaGuatemalaGuinea Guinea-BissauGuyana HaitiHondurasHong KongHungary IcelandIndiaIndonesiaIranIraqIrelandIsraelItaly JamaicaJapanJordan KazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstan LaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourg MacedoniaMadagascarMalawiMalaysiaMaldives MaliMaltaMarshall IslandsMauritaniaMauritius MexicoMicronesiaMoldovaMongoliaMoroccoMonacoMozambique NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorway Oman PakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugal Qatar RomaniaRussiaRwanda SamoaSan MarinoSao TomeSaudi ArabiaSenegal Serbia and MontenegroSeychellesSierra LeoneSingaporeSlovakia SloveniaSolomon IslandsSomaliaSouth AfricaSpain Sri LankaSudanSurinameSwazilandSwitzerlandSweden TajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistan UgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistan VanuatuVenezuelaVietnam Yemen Zimbabwe
Zip code *
Your Email Address *		Your Tel/Fax *
Special Requirements
	eg. twin beds, feather pillows, etc.

PAYMENT OPTION*

Credit Card Holder Name *
Credit Card Type *	American ExpressMastercardVisa
Credit Card Number *
Expiry Date Month *	Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec / 200920102011201220132014

OTHER INFOMATION*

Preferred transfer from Bangkok International Airport: By Car to Chiva-Som Own Arrangements

Preferred way for Chiva-Som to reply to you: EmailPhone

Is it your first time to visit Chiva-Som?: yes no

Note:
You can print and fill in details as required and send via fax or mail to the following:
Mail: Chiva-Som, 73/4 Petchkasem Road, Hua Hin, Thailand 77110
Fax: +(66) 32 511 154
Phone: +(66) 32 536 536
E-mail: reservation@chivasom.com or reserv@chivasom.com