Conference on Algebraic Topology CAT'05
June 27 - July 1, 2005
Cracow (Kraków), Poland
Please FILL THIS FORM, PRINT OUT, SIGN AND FAX it to:
48 (22) 554 4100
I authorize the Warsaw University to charge my credit card in the amount of:
Polish Zloty (PLN).
The charge includes (please check):
250 PLN for Participant's conference fee.
1500 PLN for a single room and board.
1050 PLN per person for a double room and board.
1050 PLN per accompanying person for a double room and board.
Conference Participant:
VISA
MasterCard
Name of the card holder:
Credit card number:
-
-
-
Expiration Date:
(mm/yy)
Credit card billing address:
Cardholder's Signature:
________________________________
Date: