EUROMEDIA 2004 -- Fax/Mail Registration Form

EUROMEDIA 2004
Hasselt, Belgium, 19-21 April 2004
FAX/MAIL REGISTRATION FORM
(or use the electronic form)

WORKSHOP PARTICIPANTS, PLEASE USE THIS LINKED 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 MARCH 30TH. After March 30th, prices will be 10% higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member 475 EURO Member Number:_____________________________	EUR ___________
2. [ ] Members of Sponsor or Affiliate Society 475 EUR Circle your affiliation: SISO	EUR ___________
3. [ ] Non-Member Participant 535 EUR	EUR ___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay: 300 EUR	EUR ___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees and social program,) One Day Participants and Non-Aothor Students cannot participate in the conference dinner.
5. [ ] Conference Dinner Ticket for Companion 60 EUR	EUR
6. [ ] Extra Conference Proceedings 40 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 ___________
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	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 EUROMEDIA'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,
European Simulation Office
Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941