Third Workshop on Electronics for LHC Experiments

             Text Registration Form
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First Name:    __________________________________

Last Name:     __________________________________

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E-mail Address:__________________________________

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Do you wish to bring a guest to the dinner on the final night?

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Cost

Academic:      250 pounds sterling
Industrial:    300 pounds sterling

Guest for dinner on the final night: 30 pounds sterling

Payment is only accepted by credit card.

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Expiry Date:   __________________________________

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Please return your completed form to:

Piera Brambilla
HEP Group
Physics Department
Imperial College
London
SW7 2BZ
United Kingdom

Phone + 44 171 594 7824
Fax   + 44 171 823 8830
E-mail: p.brambilla@ic.ac.uk