HEP2005 International Europhysics Conference on High Energy Physics July 21st to July 27th, 2005 Lisbon, Portugal --------------------------------------------------------------------- LIP reservation form - Residential Italia deadline: 20-Jun-2005 --------------------------------------------------------------------- FAMILY NAME: _____________________________________________________ FIRST NAME: _____________________________________________________ INSTITUTION: _____________________________________________________ ADDRESS: _____________________________________________________ _____________________________________________________ PHONE: _____________________________________________________ FACSIMILE: _____________________________________________________ (TYPE AN "X" IN THE SPACES CORRESPONDING TO YOUR CHOICES) Please book me a ___ Single (40 Euro/day) ___ Double (50 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 Residencial Italia Av. Visconde de Valmor, 67 1050-239 Lisboa, Portugal Fax: +351-21-761-1499 Tel: +351-21-761-1490 ---------------------------------------------------------------------