MESM'2004

Registration Form

 

 

FAX/MAIL REGISTRATION FORM
 
(or use the electronic form)


Please legibly print or type and fill out completely.

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

 

REGISTRATION AND PAYMENT (PRICES VALID TILL SEPTEMBER 10TH)
A.CONFERENCE REGISTRATION
(Check appropriate boxes)
1. [ ] EUROSIS member EUR 485
Member Number:_____________________________
EUR
___________
2. [ ] Participant from the Middle East
EUR 300
EUR
___________
3. [ ] Non-Member Participant
EUR 545
EUR
___________
4. [ ] For registration AFTER September 10, add
EUR 50
EUR
___________
5. [ ] Students, who are not authors but who wish to attend the conference pay:
EUR 175
EUR
___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees and social program, except for non-author students where the Conference Proceedings are NOT INCLUDED.)  
6. [ ] Conference Dinner Ticket for Companion
EUR 40
EUR
___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE EUR
___________
ADD BANK CHARGE of  (EUR 15) 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 MESM 2004
[ ] 2) Or pay by CHEQUEand send it to Philippe Geril, ETI-EUROSIS, European Simulation Office, Ghent University, Coupure Links 653, B-9000, Ghent, Belgium.
[ ] 3) Or pay by CREDIT CARDand fill in the information below:
Charge my (tick one): [ ]Visa [ ] Euro/Mastercard [ ] American Express [ ]Diners

CARD NO: __ __ __ __ : __ __ __ __ : __ __ __ __ : __ __ __ __ EXP.DATE: __ __ / __ __

Authorizing Signature:
  

PURCHASE ORDERS ARE NOT ACCEPTED UNLESS GUARANTEED BY A CREDIT CARD NUMBER.
 CREDIT CARDS EXPIRING THE MONTH OF REGISTRATION ARE NOT ACCEPTED.

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


Page created by Philippe Geril. Last update 05-08-04.
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