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\documentclass[draft,11pt,a4paper]{report}

\usepackage{latexsym,amsfonts}

\setlength{\parindent}{0 pt}

\setlength{\textwidth}{6.5 in}

\setlength{\textheight}{9in}

\setlength{\oddsidemargin}{-0.2in}

\setlength{\topmargin}{-0.5in}

\pagestyle{empty}

 

 

\begin{document}

 

\begin{center}

{\bf\Large Finite Geometries\\[3mm]  Fourth Irsee Conference}\\[3mm]

{\large Sunday 14 to Saturday 20 September 2014}

\end{center}

 

\vspace{2mm}

 

 

\begin{center}

\textbf{Registration Form}

\end{center}

 

\vspace{1pt}

 

\begin{center}

\textit{Personal Data}

\end{center}

 

\vspace{2mm}

 

Name:  \quad \underline{\hspace{120mm}}

\\[3mm]

Affiliation:  \quad \underline{\hspace{120mm}}

\\[3mm]

Mailing Address: \quad \underline{\hspace{110mm}}

\\[3mm]

City:  \quad \underline{\hspace{50mm}}  \quad Postal Code/ZIP: \quad

\underline{\hspace{40mm}}  \quad

\\[3mm]

Country:  \quad \underline{\hspace{50mm}}

\\[3mm]

Telephone: \quad Office  \underline{ \hspace{50mm}} Home \underline{\hspace{50mm}}

\\[3mm]

Fax: \quad \underline{\hspace{60mm}}

\\[3mm]

E-mail address: \quad \underline{\hspace{100mm}}

 

\vspace{5mm}

 

\begin{center}

*****************************************************************************

\end{center}

 

Do you intend to give a talk? $\quad\Box$  Yes $\quad\Box$ No\\

Do you intend to submit a paper to the Special Volume? $\quad\Box$  Yes $\quad\Box$ No\\

Check type of accommodation requested:  $\quad\Box$ Single room

         $\quad\Box$ Double room \\

If you request a double room, name person whom you want to share the room with:

\\[-2mm]

 

\hspace{40mm} \underline{\hspace{80mm}}

\begin{center}

*****************************************************************************

 

 

\vspace{5mm}

 

\textit{Fees}

\end{center}

\vspace{2mm}

 

\hfil\begin{tabular}{|l|l|}

\hline

Registration fee \qquad\qquad &  EUR \qquad\qquad\qquad \\

\hline

Accommodation   \qquad\qquad & EUR  \qquad\qquad\qquad  \\

 

\hline

\hline

\textit{Total  amount} & EUR \\

\hline

\end{tabular}

 

\vspace{5mm}

 

Please charge my credit card:  \quad $\quad\Box$  Visa  $\quad\Box$ Mastercard

  $\quad\Box$ American Express

 

Card number  \quad \underline{\hspace{50mm}}  \quad Expiry date: \quad

\underline{\hspace{30mm}}  \quad \\[2mm]

Date  \quad \underline{\hspace{40mm}}  \quad Signature: \quad

\underline{\hspace{60mm}}  \quad

 

 

\end{document}