GAMEON'2010 Registration Form

(Or use the fax reply form)

Please note: This form does NOT work with Internet Explorer 3.02 or lower. It does work fine with all versions of Firefox and higher versions of Explorer.

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

Personal Information

Title:

First Name:

Surname:

Occupation and/or Title:

Affiliation:

Address:

Zipcode:

City:

Country:

Telephone:

Fax:

E-Mail:

user email

Payment information

Payment method:

I will make payment by BANK TRANSFER to account No. 001-4081477-84 European Technology Institute, ETI Bvba, BNP PARIBAS FORTIS BANK, Torhoutsesteenweg 195, B-8400 Ostend, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and GAMEON 2010 (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, Greenbridge NV, Wetenschapspark 1, Plassendale 1, B-8400, Ostend, 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.

Credit card information

Type of card:

Card no:

Cardholder name:

Expiration date:

Verification code:

Optional

GAMEON'2010 Registration Form

(Or use the fax reply form)

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