EUROMEDIA'2004, E-Mail Registration Form

MEDIATEC'2004

ELECTRONIC REGISTRATION FORM
( or use the fax-reply form)

ELECTRONIC REPLY 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 from version IE 4.0. onwards

First Name:
Surname:
Occupation and/or Title:
Affiliation:
Mailing Address:
Zipcode:
City:
Country:
Telephone:
Fax:
E-mail:

Yes, I will attend the 2004 EUROMEDIA Conference at Huize Corswarem. Hasselt, Belgium

A. Conference Registration. (Fill in 1/2/3 and 4/5/6/7 if necessary)

1. EUROSIS Conference Member EUR 475
EUROSIS member number:
2. Affiliated participant EUR 475
3. Non-Member participant EUR 535
4. Late registration surcharge after March 30, add: EUR 50
5. Students who are not authors EUR 300
6. Extra Conference Dinner ticket for companion. EUR 60
7. Add bank charge if necessary when paying by bank transfer or cheque EUR 15
8. ADD 21% VAT. THIS VAT (Value Added Tax) CAN BE RECLAIMED BY ADDING YOUR VAT NUMBER AND SENDING IN THE VAT FORM GIVEN AT THE CONFERENCE -THIS IS AN OBLIGATORY PAYMENT
TOTAL AMOUNT TO PAY (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, Kouter 6-8, B-9000 Ghent, Belgium
IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and EUROMEDIA 2004 (make a print of this form so you know what you submitted)

I will pay by CHEQUE and send it to Philippe Geril, ETI-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 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 you would like to receive more information about EUROSIS and its activities, please tick the following box:
YES, I would like to know more about EUROSIS.
NO, please remove me from your database.

If e-mail fails, you can also print this information and send / fax it to:
Philippe Geril,
European Simulation Office, Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941