ANTS V Credit Card Form

ANTS V Credit Card Form ANTS V Registration Form

To: School of Mathematics and Statistics, University of Sydney, Australia.
Attn: Claus Fieker

Name: ________________________________________________________

I wish to attend the ANTS V conference: ( )

Please charge my credit card

for the amount of: AUD _____________________

I will attend the conference dinner (AUD 65): ( ) with ( ) additional persons.

I want to book college accommodation: ( )

I need a twin room: ( )

I will arrive at: _____________________

I will depart at: _____________________

I claim reduced registration fee: ( )

credit card number _______________________________________________

( ) VISA ( ) Mastercard

expiration date _______________________________________________

name on credit card _______________________________________________

signature _______________________________________________

Please print this form, fill it out, and send it by fax to:

fax + 61 2 9351 4534

Attn: Claus Fieker

I will arrive at:	_____________________
I will depart at:	_____________________
I claim reduced registration fee: ( )
credit card number	_______________________________________________
	( ) VISA ( ) Mastercard


expiration date	_______________________________________________

name on credit card	_______________________________________________


signature	_______________________________________________