_________________________________________________________________________________
First Name
Middle Initial
Family Name
_________________________________________________________________________________
Organization or Affiliation
_________________________________________________________________________________
Organization Address
________________________________________________________________________________
City
State
Postal Code
Country
_____________________________
____________________________
Organization Telephone
FAX Number
_____________________________
Email Address
[ ] I have the following special needs________________________________________
[ ] Male [
] Female
LODGING (includes 3 night’s lodging, 3 full breakfasts, 3 lunches,
2 dinners, use of recreational facilities. Should you require
additional nights lodging, please contact Local Arrangements Coordinator
Roberta Boucher rlboucher@lbl.gov)
Single Occupancy $333.00 per participant $____________
Guest/Spouse $162.00 per person
$____________
(this rate applies to guests sharing a single occupancy room
with a participant)
Total Lodging Costs
$____________
REGISTRATION (covers meeting materials, coffee breaks, facility charges, and other meeting costs)
Registration Fee
$242.00
$____________
TOTAL FEES (LODGING + REGISTRATION)
$____________
We are unable to accept International Postal Money Orders, or Eurochecks.
Please enclose check in U.S. dollars drawn on a U.S. bank or International
Money Order payable to: REGENTS, UNIVERSITY OF CALIFORNIA
We accept payment by mail or fax using either Visa, Mastercard, Diners
Club, JCB or Carte Blanche.
Please complete the following information:
_______________
___________________________________
_________________
Type of credit card
Credit card Number
Expiration date
_________________________________
___________________________
Print name as shown on credit card
Signature
Return this form with your payment before March 31, 1999 to:
Conference Coordinator
Lawrence Berkeley Laboratory
Mailstop 936A
Berkeley, California 94720 USA
FAX: (510) 486-6282
Notices
Cancellations must be received in writing before April 18th, 1999. A $100.00 handling charge will fee will be charged to all cancellations before April 18th. Refunds will not be possible after April 18th.
Lodging at Granlibakken is sold as a package, with arrival Sunday, May
2nd and departure Wednesday, May 5th. Refunds cannot be given for late
arrivals or early departures.