Lattice '99 Reservation Receipt Form

Please use this form to notify the booking agency about the payment of your reservation charges (by bank transfer or certified bank cheque) for the Lattice '99 conference.

Print this page, fill it in, and fax it to +39-050-503456, or otherwise send it to L&B Studio.

Last Name:                    _________________________

First Name:                   _________________________

E-mail:                       _________________________

Mailing Address:              _________________________


Hotel/housing deposit E ______

Reservation fee       E   7.30

Bank charges          E ______

Total amount          E ______

Please include a copy of your bank transfer receipt or certified cheque, either below or on a separate sheet.