Third International Workshop on Astronomy at Dome C

Kingston, Tasmania - 28-29 June 2001

REGISTRATION CREDIT CARD PAYMENT FORM

This form is for conference participants wishing to pay their registration fee, accommodation deposit and/or conference dinner by credit card. Simply complete this form, giving your credit card details, and fax to: Jon Everett, UNSW fax: +61 (2) 9385 6060 (Please note that number has been updated!)

NOTE: We do not have a secure server so PLEASE DO NOT send your credit card details by email.

Name:_____________________________________________________

Affiliation:________________________________________

Postal Address:____________________________________________________________________________________

                      _____________________________________________________________________________________

Email:______________________________________________

Phone:_____________________________________________

Fax:  ______________________________________________

Registration Fee: 100 AU$ - Dinner: 50 AU$ ea.

Please debit my credit card with the sum of AU$__________________

Name on card:____________________________________

Card Number:____________________________________

Expiry date:_____________________________________

Signature:_______________________________________

Date (day / month / year)___________________________