HEP2005 Conference Registration
                        21 - 27 July, 2005, Lisboa, Portugal
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                                REGISTRATION FORM

   IDENTIFICATION

     Family Name: ______________________________________________________

      First Name: ______________________________________________________

      Experiment: ______________________________________________________

     Institution: ______________________________________________________

         Address: ______________________________________________________

                  ______________________________________________________

                  ______________________________________________________

          e-mail: ______________________________________________________

       Telephone: ______________________________________________________

       Facsimile: ______________________________________________________

   CONFERENCE FEE: 350.00 Euro
                   100.00 Euro for pre-laureate students

     Payed by bank transfer: ___ Bank name: Millenium BCP
                                      IBAN: PT50003300000001303380375
                                 BIC/SWIFT: BCOMPTPL
                        (mention name and institute. Free of charges to LIP)

     Credit Card:  ___Visa  ___Eurocard  ___Mastercard  ___American Express 

                   Credit Card Number: ________________________________

          Credit Card Security Number: ________________________________

                     Credit Card Name: ________________________________

                          Expiry date: ____/____  (e.g. 11/05)


                          Signature: __________________________________

   OTHER INFORMATIONS

            Ride: __ Yes / __ No      Nb. of Persons: ___
    Conf. Dinner: __ Yes / __ No      (add 75 Euro for each accompanying
                                       who wish to go on the excursion)

        Comments: _________________________________________________________

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   _________________________________________________________________________
      LIP, HEP2005 Secretariat, Av. Elias Garcia, 14, P-1000-149 Lisboa
            Fax: +351-21-793-4631           Tel: +351-21-797-3880