GAMEON 2009 -- Fax/Mail Registration Form

GAMEON_© 2009
Mediadesign Hochschule, Duesseldorf, Germany
26-28 November 2009
FAX/MAIL REGISTRATION FORM
(or use the electronic 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 NOVEMBER 15TH. After November 15th, prices will be €50 higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member € 495 Member Number:_____________________________	€ ___________
2. [ ] Members of Sponsor or Affiliate Society € 495	€ ___________
3. [ ] Non-Member Participant € 545	€ ___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay:€ 360	€ ___________
(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 € 60	€ ___________
6. [ ] Extra Lunch Ticket € 25	€ ___________
7. [ ] Extra Conference Proceedings € 50	€ ___________
8. [ ] Late Payment Charge (after October 25th) € 50	€ ___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE	€ ___________
ADD BANK CHARGE of €15 in case you pay by BANK or CHEQUE.	€ ___________
TOTAL AMOUNT REMITTED	€ ___________

[ ] 1)	Make payment by BANK TRANSFER to account No. 001-4081477-84 EUROPEAN TECHNOLOGY INSTITUTE, ETI Bvba, BNP PARIBAS FORTIS BANK, Torhoutsesteenweg 192, B-8400 Ostend, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and GAMEON'2009
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, 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

PURCHASE ORDERS ARE NOT ACCEPTED UNLESS GUARANTEED BY A CREDIT CARD

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