ESM 2006 -- Fax/Mail Registration Form

ESM 2006
LAAS-CNRS, Toulouse, France
23-25 October 2006
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 OCTOBER 15TH. After October 15th, prices will be 50 EUR higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member 485 EUR Member Number:_____________________________	_________EUR
2. [ ] Members of Sponsor or Affiliate Society 485 EUR Circle your affiliation: SISO	_________ EUR
3. [ ] Non-Member Participant 545 EUR	_________EUR
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay: 350 EUR	_________EUR
(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. [ ] Tutorial only Registration for students: 25 EUR. for non students: 75 EUR	_________EUR
5. [ ] Conference Dinner Ticket for Companion 60 EUR (indicate if you require [] vegetarian or [] hallal food)	_________EUR
6. [ ] Extra Lunch Ticket 20 EUR (indicate if you require [] vegetarian or [] hallal food)	_________EUR
7. [ ] Extra Conference Proceedings 50 EUR	_________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% shipping costs and VAT if applicable	_________EUR
9. [ ] Late Payment Charge (after October 15th) 50 EUR	_________EUR
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE	_________EUR
ADD BANK CHARGE of 15 EUR 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, 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
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, University of Ghent, Faculty of Engineering, Dept.of Industrial Management, Technologiepark 903, B-9052, Zwijnaarde-Ghent, 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
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