ESMc 2003 -- Electronic Registration Form

ESM© 2003
Naples, Italy, 27-29 October 2003
ELECTRONIC REPLY FORM
(or use the fax/mail form)

ELECTRONIC REGISTRATION FORM
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

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

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

Yes, I will attend the 2003 ESMc conference.

A. Conference Registration. (Fill in 1/2/3/4 and 5/6/7 if necessary) - PRE-CONFERENCE PRICES VALID TILL OCTOBER 15TH. After October 15th, prices will be 10% higher.

1. EUROSIS Conference Member EUR 475
EUROSIS member number:
2. Member of Sponsor or Affiliate Society EUR 475
Affiliation Society:	SISO
3. Non-Member participant EUR 535
4. Students who are not authors or a ONE DAY registration EUR 300
5. Extra Conference Dinner ticket for companion. EUR 50
6. Extra Conference Proceedings EUR 50
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. 001-3949607-37 EUROSIS, FORTIS BANK, Branch Office Ghent Centre, Kouter 6, B-9000 Ghent, Belgium IBAN CODE: BE35 0013 9496 0737, SWIFT CODE: GEBABEBB05A, MENTION YOUR NAME and ESM©'2003 (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, European Simulation Office, Ghent University, Coupure Links 653, B-9000, 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,
European Simulation Office, Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941