COMPASS Collaboration Meeting 1 - 3 October, 2003 Lisbon, Portugal --------------------------------------------------------------------- RESERVATION FORM - PENSÃO RESIDÊNCIA IMPERADOR --------------------------------------------------------------------- FAMILY NAME: _____________________________________________________ FIRST NAME: _____________________________________________________ INSTITUTION: _____________________________________________________ ADDRESS: _____________________________________________________ _____________________________________________________ PHONE: _____________________________________________________ FACSIMILE: _____________________________________________________ (TYPE AN "X" IN THE SPACES CORRESPONDING TO YOUR CHOICES) Please book me a ___ Single Room (40 Euro/day) ___ Double Room (50 Euro/day) (breakfast included) Date of arrival: 2003/____/___ Date of departure: 2003/____/___ ___Visa ___Eurocard ___Mastercard ___American Express Credit card number: _____________________________________ Credit card name: _____________________________________ Expiry date: ____/___ (e.g. 11/03) Signature: _____________________________________________ --------------------------------------------------------------------- PRINT and send by FAX to PENSÃO RESIDÊNCIA IMPERADOR Av. 5 de Outubro, 55 1050-048 Lisboa, Portugal Fax: +351 213 526 537 Tel: +351 213 524 884 ---------------------------------------------------------------------