EUROMEDIA 2009 -- Fax/Mail Registration Form

EUROMEDIA 2009
Bruges, Belgium, 15-17 April 2009
FAX/MAIL REGISTRATION FORM

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 MARCH 25TH. After March 25th, prices will be 50 EUR higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member EUR 495 Member Number:_____________________________	EUR ___________
2. [ ] Members of Sponsor or Affiliate Society EUR 495 Circle your affiliation: SISO	EUR ___________
3. [ ] Non-Member Participant EUR 555	EUR ___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay EUR 350	EUR ___________
(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.	EUR
5. [ ] Conference Dinner Ticket for Companion EUR 60	EUR ___________
6. [ ] Extra Conference Proceedings EUR 40	EUR ___________
VAT Number if applicable: _______________________________
7.[ ] ADD 21% VAT	EUR
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, Torhoutsesteenweg 195, B-8400 Ostend, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and EUROMEDIA'2009
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, Greenbridge NV, Wetenschapspark 1, Plassendale 1, B-8400, Ostend, 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

MAIL REGISTRATION FORM AND PAYMENT FORM COPY (1) / CHEQUE (2) / CREDITCARD INFO (3) TO:
Philippe Geril, EUROSIS-ETI,
European Simulation Office
Greenbridge NV,
Wetenschapspark 1,
Plassendale 1 , B-8400, Ostend, Belgium.
Phone: +32-59-255.330, Fax: +32-59-255.339