EUROMEDIA'2007 -- Electronic Registration Form

EUROMEDIA'2007
Delft, The Netherlands, 25-27 April 2007
ELECTRONIC REGISTRATION FORM

ELECTRONIC REGISTRATION FORM - THIS FORM WILL BE UPGRADED ASAP UNDER DRUPAL
Please note: This form does NOT work with Internet Explorer 3.02 or lower.
It does work fine with all versions of Netscape and higher versions of IE

Title
First Name:
Surname:
Occupation and/or Title:
Affiliation:
Mailing Address:

Zipcode:
City:
Country:
Telephone:
Fax:
E-mail:

Yes, I will attend the 2007 EUROMEDIA conference.

A. Conference Registration. (Fill in 1/2/3/4 and 5/6/7 if necessary) -
PRE-CONFERENCE PRICES VALID TILL APRIL 20TH. After April 20th, prices will be 10% higher.

1. EUROSIS Conference Member EUR 485
EUROSIS member number:
2. Member of Sponsor or Affiliate Society EUR 485
Affiliation Society:	SISO
3. Non-Member participant EUR 545
4. Students who are NOT authors or a ONE DAY registration EUR 300
5. Extra Conference Dinner ticket for companion. EUR 60
6. Extra Conference Proceedings EUR 40
7. Add bank charge if necessary when paying by bank transfer or cheque EUR 10
TOTAL AMOUNT TO PAY IN EUR

B. PAYMENT INFORMATION

I will make payment by BANK TRANSFER to account No. 001-4081477-84 European Technology Institute,
ETI Bvba, FORTIS BANK, Branch Office Ghent Centre, Zonnestraat 2, B-9000 Ghent, Belgium
IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and
EUROMEDIA 2007 (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 CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, Ghent University,
Faculty of Engineering, Dept.of Industrial Management, Technologiepark 903 , B-9052, Zwijnaarde-Ghent, Belgium.
(make a print of this form so you know what you submitted)

I will pay by CREDIT CARD but do not send the information with the form. Please phone me for the credit card information

I will pay by CREDIT CARD and fill in the information below. Please note: credit card information is NOT encrypted YET in the e-mail.
If this is a problem: fax the credit card information separately, or discuss the payment information with Philippe Geril by phone or by e-mail.

Type of card
Card no
Cardholder name
Exp.Date

If e-mail fails, you can also print this information and send / fax it 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