Please legibly print or type and fill out completely.
|COMPANY OR AFFILIATION
|Mailing address (tick one): [ ] HOME [ ] BUSINESS|
PRICES VALID TILL APRIL 5TH. After April 5th, prices will be 10% higher.
CONFERENCE REGISTRATION (Check appropriate boxes)
|1. [ ] EUROSIS member
|2. [ ] Members of Sponsor
or Affiliate Society
Circle your affiliation: SISO
|3. [ ] Non-Member Participant 545|| ___________|
|4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay: 300|| ___________|
|(Above registration fees
include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments,
and social program,) One Day Participants and Non-Author Students cannot participate in the conference dinner.
|5. [ ] Conference Dinner Ticket for Companion 50|| ___________|
|6. [ ] Extra Conference Proceedings 40|| ___________|
|VAT Number if applicable: _______________________________|
|TOTAL AMOUNT DUE|| ___________|
|ADD BANK CHARGE of 15 in case you pay by BANK or CHEQUE.|| ___________|
|TOTAL AMOUNT REMITTED|| ___________|
[ ] 1)
Make payment by BANK TRANSFER to account No. 001-4081477-84 EUROPEAN TECHNOLOGY INSTITUTE, ETI Bvba,
FORTIS BANK, Branch Office Ghent Centre, Kouter, B-9000 Ghent, Belgium
IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84
MENTION YOUR NAME and EUROMEDIA'2005
|[ ] 2)||Or pay by CHEQUE and send
it to Philippe Geril, EUROSIS-ETI, European Simulation Office,
University of Ghent, Faculty of Engineering, Dept.of Industrial Management, Technologiepark 903,
B-9052, Zwijnaarde-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: __ __ / __ __
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
Faculty of Engineering, Dept.of Industrial Management,
Technologiepark 903 , B-9052, Zwijnaarde-Ghent, Belgium.
Phone: +32-9-264.55.09, Fax: +32-9-264.58.25
Page created by Philippe Geril . Last update
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