First Name Middle Initial Family Name
Organization or Affiliation
City State Postal Code Country
Organization Telephone FAX Number
[ ] I have the following special needs________________________________________
[ ] Male [
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 email@example.com)
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)
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:
Lawrence Berkeley Laboratory
Berkeley, California 94720 USA
FAX: (510) 486-6282
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.