HEP2005 International Europhysics Conference on High Energy Physics July 21st to July 27th, 2005 Lisbon, Portugal --------------------------------------------------------------------- LIP reservation form - Hotel Ibis Lisboa Malhoa deadline: none, reservation not gurantee --------------------------------------------------------------------- FAMILY NAME: _____________________________________________________ FIRST NAME: _____________________________________________________ INSTITUTION: _____________________________________________________ ADDRESS: _____________________________________________________ _____________________________________________________ PHONE: _____________________________________________________ FACSIMILE: _____________________________________________________ (TYPE AN "X" IN THE SPACES CORRESPONDING TO YOUR CHOICES) Please book me a ___ Single (57 Euro/day + 5 Euro/day for breakfast) ___ Double (57 Euro/day + 5 Euro/day/person for breakfast) 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 Hotel Ibis Lisboa Malhoa Av. Jose Malhoa, Lt. H 1070-158 Lisboa, Portugal Fax: +351-21-723-5701 Tel: +351-21-723-5700 ---------------------------------------------------------------------