ESM'2006 -- Electronic Registration Form

ESM'2006
Toulouse, France, 23-25 October 2006
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

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

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

Yes, I will attend the 2006 ESM conference.

A. Conference Registration. (Fill in 1/2/3/4 and 5/6/7 if necessary) - PRE-CONFERENCE PRICES VALID TILL OCTOBER 15. After October 15, prices will be 50 EUR higher.

1. EUROSIS Conference Member 485 EUR
EUROSIS member number:
2. Member of Sponsor or Affiliate Society 485 EUR
Affiliation Society:	SISO
3. Non-Member participant 545 EUR
4. Students who are NOT authors or a ONE DAY registration 350 EUR
5. Tutorial Only registration for students:€ 25 .for non students: 75 EUR
6. Extra Conference Dinner ticket for companion. 60 EUR (indicate if you require [] vegetarian or [] hallal food)
7. Extra Conference Lunch ticket for companion. 20 EUR (indicate if you require [] vegetarian or [] hallal food)
8. Extra Conference Proceedings 50 EUR
8. I will not be able to attend the conference but would like to order a copy of the Proceedings 60 EUR plus 15 percent shipping costs and VAT if applicable
10. Add bank charge if necessary when paying by bank transfer or cheque 15 EUR
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
ESM 2006 (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