Lattice '99 Registration Payment Form

Please use this form to pay by credit card for your registration for the Lattice '99 conference.

Print this page, fill it in, and fax it to +39-050-844306, or otherwise send it to the conference organizers.

Last Name:                    _________________________

First Name:                   _________________________

E-mail:                       _________________________

Mailing Address:              _________________________


Card type: ( ) Visa / ( ) Master Card

Credit Card N.:               _________________________

Expiry date:                  _________________________

Name (as it appears on card): _________________________

Conference fee (by April 29):      E ______

Late registration conference fee:  E ______

Excursion tickets for companions:  E ______

Banquet tickets for companions:    E ______

Total amount:                      E ______

I authorize the use of my credit card for this purpose

Date:  ____________________       Signature: ____________________