EUROSIS Electronic Membership Form

Please note: This form does NOT work with Internet Explorer 3.02 or lower. It does work fine with all versions of Firefox, Opera, Google Chrome and higher versions of Explorer.

If e-mail fails, you can also print this information and send / fax it to:
Philippe Geril, EUROSIS-ETI,
European Simulation Office
Romestraat 19 B.04.02
B-8400, Ostend, Belgium.
Phone: +32-473.231.297

Personal Information

Title:

First Name:

Surname:

Occupation and/or Title:

Affiliation:

Address:

Zipcode:

City:

Country:

Telephone:

Fax:

E-Mail:

user email

TC Information

Position in TC:

Chairman

Secretary

EU Liaison Officer

Inter TC Liaison Officer

Payment information

Payment method:

I will make payment by BANK TRANSFER to account No. IBAN CODE: BE36 0015 8422 1881, BIC Code: GEBABEBB, BNP Paribas Fortis Bank, Torhoutsesteenweg 356, B-8400 Ostend, Belgium. Account Account Holder: EUROSIS VZW. MENTION YOUR NAME (make a print of this form so you know what you submitted) and ADD A COPY OF PAYMENT TO THIS FORM. ALSO MAKE SURE THE CORRECT AMOUNT IS DEPOSITED INTO THE ACCOUNT.

I will pay by CREDIT CARD but do not send the information with the form. Please phone me for the credit card information

I will pay by CREDIT CARD and fill in the information below.

Credit card information

Type of card:

Card no:

Cardholder name:

Expiration date:

Verification code:

Optional

EUROSIS Electronic Membership Form

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