EUROMEDIA 2004 -- Fax/Mail Registration Form

EUROMEDIA 2004
Hasselt, Belgium, 20 April 2004
DATAMANAGEMENT WORKSHOP
FAX/MAIL REGISTRATION FORM

Please legibly print or type and fill out completely.

FIRST NAME	LAST NAME	M.I.
COMPANY OR AFFILIATION
Mailing address (tick one): [ ] HOME [ ] BUSINESS
STREET
CITY
ZIPCODE	COUNTRY
TELEPHONE	FAX
E-MAIL
DATE	SIGNATURE

PRICES VALID TILL APRIL 10TH. After April 10th, prices will be 10% higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] 225 EURO	EUR ___________
(Above registration fees include, one copy of the workshop programme, midday meal, refreshments, coffees)
2. [ ] Conference Dinner Ticket for Companion 60 EUR	EUR
3. [ ] Extra ECEC-EUROMEDIA Conference Proceedings 40 EUR	EUR ___________
VAT Number if applicable: _______________________________
By using the special "Opleidingscheques" provided by the ministry of education, you can save 50% on the registration fee. if you want to use those cheques please contact Philippe.Geril@ugent.be	EUR ___________
TOTAL AMOUNT DUE	EUR ___________
ADD BANK CHARGE of 15 EUR in case you pay by BANK or CHEQUE.	EUR ___________
ADD 21% VAT. THIS VAT (Value Added Tax) CAN BE RECLAIMED BY ADDING YOUR VAT NUMBER AND SENDING IN THE VAT FORM GIVEN AT THE CONFERENCE -THIS IS AN OBLIGATORY PAYMENT	EUR
TOTAL AMOUNT REMITTED	EUR ___________

[ ] 1)	Make payment by BANK TRANSFER to account No. 001-4081477-84 EUROPEAN TECHNOLOGY INSTITUTE, ETI Bvba, FORTIS BANK, Branch Office Ghent Centre, Kouter 6-8, B-9000 Ghent, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and WORKSHOP'2004
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, University of Ghent, Coupure Links 653, B-9000, Ghent, Belgium.
[ ] 3)	Or pay by CREDIT CARD and fill in the information below:
	Charge my (tick one): [ ]Visa [ ] Euro/Mastercard [ ] American Express [ ]Diners CARD NO: __ __ __ __ : __ __ __ __ : __ __ __ __ : __ __ __ __ EXP.DATE: __ __ / __ __
	Authorizing Signature:
	Print Signature

PURCHASE ORDERS ARE NOT ACCEPTED UNLESS GUARANTEED BY A CREDIT CARD NUMBER.

MAIL REGISTRATION FORM AND PAYMENT FORM COPY (1) / CHEQUE (2) / CREDITCARD INFO (3) TO:
Philippe Geril, EUROSIS-ETI,
European Simulation Office
Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941