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Gary G. Ihas, Chair of LT24 and Professor
Mark W. Meisel, Secretary of LT24 and Professor
Department of Physics
Email: lt24@phys.ufl.edu
Webpage: http//www.phys.ufl.edu/~lt24
P.O. Box 118440
Gainesville, FL 32611-8440
(352) 392-5803
Fax (352) 392-7709
Payment of fees associated with LT24
FAX to: 1-352-392-7709 Attn: Mark Meisel
Date:
(Please Print or enter with word processor.)
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Credit Card:
(please circle)
MasterCard
Number on Credit Card:
Visa
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Secondary 3 digit Security Number:
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(What is this? For MC and Visa: it is the 3 digit number on the backside of the card in the right hand
region of the signature strip.)
Name as it appears on Card:
Expiration Date (mm/yr):
Billing Address for the Card:
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Total Amount to be Charged in US Dollars (USD):
$ (USD) ___________________
Authorization Signature for the Charge: _____________________________________
Printed Name of the Authorized Signature:
Email Address:
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Detailed Information about the Charge (attach additional sheets as needed):
(Please provide the Name of each Person, LTID Number, Amount, Purpose)
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