EUROMEDIA 2005
Toulouse, France, 11-13 April  2005
FAX/MAIL REGISTRATION FORM
(or use the electronic form)


EUROSIS.jpg (56941 bytes)

 

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 5TH. After April 5th, prices will be 10% higher.

REGISTRATION AND PAYMENT
CONFERENCE REGISTRATION
(Check appropriate boxes)
1. [ ] EUROSIS member € 485
Member Number:_____________________________
 € ___________
2. [ ] Members of Sponsor or Affiliate Society  € 485
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, coffees 
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: __ __ / __ __

Authorizing Signature:
  
Print Signature in CAPITALS
 

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,

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 03-03-05.
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