GAMEON'2015 Registration Form

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If e-mail fails, you can also print this information and send / fax it to:
Philippe Geril, EUROSIS-ETI,
European Simulation Office
Greenbridge Science Park
Ghent University - Ostend Campus
Wetenschapspark 1, Plassendale 1
B-8400, Ostend, Belgium.
Phone: +32-59.255.330+32-59.255.330, Fax: +32-59.255.339

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Personal Information

Title:

First Name:

Surname:

Occupation and/or Title:

Affiliation:

Address:

Zipcode:

City:

Country:

VAT Number:

Telephone:

Fax:

E-Mail:

user email

Payment information

Payment method:

I will make payment by BANK TRANSFER to account No. IBAN CODE:BE03 0014 0814 7784, BIC/SWIFT CODE: GEBABEBB, European Technology Institute, ETI Bvba, BNP PARIBAS FORTIS BANK, Torhoutsesteenweg 356, B-8400 Ostend, Belgium , MENTION YOUR NAME and GAMEON 2015 (make a print of this form so you know what you submitted) and ADD A COPY OF PAYMENT TO THIS FORM

I will pay by CREDIT CARD and fill in the information below.

Credit card information

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Card no:

Cardholder name:

Expiration date:

Verification code:

Optional

GAMEON'2015 Registration Form

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