HEP2005 International Europhysics Conference on High Energy Physics July 21st to July 27th, 2005 Lisbon, Portugal --------------------------------------------------------------------- LIP reservation Form - Hotel Astoria deadline: 31-Mar-2005 --------------------------------------------------------------------- FAMILY NAME: _____________________________________________________ FIRST NAME: _____________________________________________________ INSTITUTION: _____________________________________________________ ADDRESS: _____________________________________________________ _____________________________________________________ PHONE: _____________________________________________________ FACSIMILE: _____________________________________________________ (TYPE AN "X" IN THE SPACES CORRESPONDING TO YOUR CHOICES) Please book me a ___ Single (49.00 Euro/day) ___ Double (58.00 Euro/day) Date of arrival: ____________ Date of departure: _____________ ___Visa ___Eurocard ___Mastercard ___American Express Credit card number: _____________________________________ Credit card name: _____________________________________ Security Number: _____________________________________ Expiry date (e.g. 11/06): ____/____ Signature: _____________________________________________ --------------------------------------------------------------------- PRINT and send by fax to Astoria Rua Braamcamp, 10 1250-050 Lisboa, Portugal Fax: +351-21-386-0491 Tel: +351-21-386-1317 ---------------------------------------------------------------------