GAME'ON 2004
Ghent, Belgium, 25-27 November 2004
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 NOVEMBER 20TH. After November 20th, prices will be 10% higher.

REGISTRATION AND PAYMENT
A.CONFERENCE REGISTRATION
(Check appropriate boxes)
1. [ ] EUROSIS member 475 EURO
Member Number:_____________________________
EUR
___________
2. [ ] Members of Sponsor or Affiliate Society
475 EUR

Circle your affiliation: SISO
EUR
___________
3. [ ] Non-Member Participant
535 EUR
EUR
___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay:
300 EUR
EUR
___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees
and social program, except for students and ONE DAY PARTICIPANTS where the Conference Proceedings are NOT INCLUDED.)
5. [ ] Conference Dinner Ticket for Companion
40
EUR
EUR
6. [ ] Extra Conference Proceedings
50
EUR
EUR
___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE EUR
___________
ADD 21%  VAT (Value Added Tax) EUR
___________
ADD BANK CHARGE of 10 EUR in case you pay by BANK or CHEQUE. 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 GAME'ON 2004
[ ] 2) Or pay by CHEQUE and send it to Philippe Geril, ETI Bvba, 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,
Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941


Page created by Philippe Geril . Last update 04-11-04.
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