ESMc 2004 -- Fax/Mail Registration Form

ESM© 2004
UNESCO, Paris, France
25-27 October 2004
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 5TH. After October 5th, prices will be 50 EUR higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member 485 EURO 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. [ ] Conference Dinner Ticket for Companion 50 EUR	EUR
6. [ ] Extra Conference Proceedings 50 EUR	EUR ___________
7. [ ] Late Payment Charge (after October 5th) 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, Kouter 6-8, B-9000 Ghent, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and ESMc'2004
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, University of Ghent, Coupure Links 653, B-9000, 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 NUMBER.

MAIL REGISTRATION FORM AND PAYMENT FORM COPY (1) / CHEQUE (2) / CREDITCARD INFO (3) TO:
Philippe Geril, EUROSIS-ETI
Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941