------------------------------------------------------------------------
    -			LC2005 PAYMENT FORM			           -
    ------------------------------------------------------------------------
    
    Title: __________________ Surname: ___________________________________
    
    
    Given Names: _________________________________________________________
    
    
    Registration Type:
                         Earlybird (AUD$750 paid by 30 Apr 2005) [ ]

                                     *OR*

                         Standard  (AUD$950)  [ ]
    
    
    *****************************************************
    *                   Accompanying Guest Package:     *
    *****************************************************
    
    Number of Accompanying Guests: _______
    
    Breakfasts and/or lunches must be taken as a package 
    for the entire period. Please indicate below whether
    you wish to take all or none of the breakfasts
    and/or lunches and/or workshop dinner.

    
    Number of Additional Breakfast Packages ___ (@ A$84 p/p ) = AUD$_________

    Number of Additional Lunch Packages     ___ (@ A$140 p/p) = AUD$_________
   
    Workshop Dinner Guests                  ___ (@ A$70 p/p ) = AUD$_________
    
  
    					Guest Total:         AUD$____________

    					Plus Registration:   AUD$____________


                                        Total Payment Due:   AUD$____________

    *************************************************************************
    
    
    CREDIT CARD AUTHORIZATION:

    Name (as it appears on the card) ____________________________________

    Card Type:  VISA [ ]    Mastercard [ ] 
    (Unfortunately, we are unable to accept AMEX)
    
    Card Number ___________________________    Expiry Date __ / __

    
    "I, ____________________________, hereby authorise the amount of 

     AUD$_____________ to be debited from my credit card"
    
    
    Signed: ______________________________________________________________
    
    
    Registration may also be paid by international money order, 
    or bank cheque (drawn in Australian Dollars and on an Australian bank).
    
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    Completed form and payment by cheque or money order  should be sent to:
    
    LC2005 Workshop Organisers 
    CSSM 
    Physics Building, Rm. 126
    University of Adelaide 
    Adelaide,  SA 5005, Australia
    Telephone: +61-8-83033533

    OR

    Fax form with credit card details to
    +61-8-83033551


    Further enquiries should be directed to LC2005@physics.adelaide.edu.au